NJ Form MR-4 Medical Emergency Report Guide

NJ Form MR-4 Medical Emergency Report Guide – The New Jersey Motor Vehicle Commission (MVC) Form MR-4, officially titled the Medical Emergency Report, is a critical document used by physicians and emergency room providers to report certain medical conditions that may affect a person’s ability to drive safely. This form helps the MVC identify high-risk drivers and take appropriate action to protect public safety on New Jersey roads.

Under New Jersey law, physicians have a specific legal duty to report certain conditions promptly. Understanding Form MR-4 is essential for medical professionals, drivers, and family members concerned about medical fitness to drive.

What Is New Jersey Form MR-4?

Form MR-4 is the official Medical Emergency Report issued by the New Jersey Motor Vehicle Commission. Physicians use this form to notify the MVC’s Medical Review Unit when a patient age 16 or older has medical conditions that could impair safe driving.

The form collects key details about the patient and their medical history, including seizure or unconsciousness episodes, EEG results (if performed), and the reporting physician’s information. It is revised periodically; the current version is marked MR-4 (R06/22).

You can download the official Form MR-4 directly from the New Jersey Motor Vehicle Commission here: Download New Jersey Form MR-4 (PDF).

Legal Requirements for Reporting: N.J.S.A. 39:3-10.4

New Jersey law (N.J.S.A. 39:3-10.4) requires every physician treating a person 16 years of age or older to report to the Motor Vehicle Commission within 24 hours after determining that the patient experiences:

Recurrent convulsive seizures
Recurrent periods of unconsciousness or impairment
Impairment or loss of motor coordination due to conditions such as, but not limited to, epilepsy in any of its forms, when such conditions persist or recur despite medical treatment

This mandatory reporting requirement exists to reduce the risk of medically related motor vehicle crashes. The law directs the MVC (in consultation with the State Commissioner of Health) to prescribe the official reporting forms—Form MR-4 serves this purpose.

Physicians who fail to report as required may face a fine. Drivers themselves also have related reporting obligations under related statutes when applying for or renewing a license.

Who Must File Form MR-4?

Form MR-4 is primarily completed and submitted by:

Licensed physicians treating patients with the conditions listed above
Emergency room physicians and other medical providers who make the determination

Law enforcement officers use a different form (MR-5: Driver Examination/Medical Evaluation Request) when they observe potential medical impairment during traffic stops or crash investigations. Family members and other concerned parties generally submit written letters rather than Form MR-4.

Anonymous reports are not accepted by the MVC Medical Review Unit.

Information Required on Form MR-4

The form is straightforward and asks for the following information (print or type clearly):

Patient’s full name
Address
Date of birth
Eye color
Sex
Driver license number
History of the condition (date of onset, frequency during the past year, date of last occurrence)
Whether an EEG was performed (Yes/No), date, place, results, and who read the results
Resulting classification (Gran mal, Focal, Petit mal, Psychomotor, Convulsions (other), or Unconsciousness (other))
Remarks / additional clinical notes
Reporting physician’s name, specialty, signature, phone number, and date

Accurate and complete information helps the Medical Review Unit process the case efficiently and determine appropriate next steps.

How to Complete and Submit Form MR-4?

Follow these steps to file the Medical Emergency Report correctly:

Download the current official form from the New Jersey MVC website: MVC Form MR-4 PDF.
Complete all applicable fields. Provide clinical details that support the determination that the condition persists or recurs despite treatment.
Sign and date the form. Include a contact phone number so the Medical Review Unit can reach you if needed.
Submit the completed form by fax or mail to the MVC Medical Review Unit.

Submission details:

Fax: (609) 292-7504
Mail: New Jersey Motor Vehicle Commission, Medical Review Unit, P.O. Box 173, Trenton, NJ 08666-0173
Phone for questions: (609) 292-7500, extension 5032

Reports must be filed within 24 hours of the physician’s determination. Timely submission is both a legal requirement and critical for public safety.

What Happens After Form MR-4 Is Submitted?

Once the Medical Review Unit receives Form MR-4, the following process typically occurs:

The unit reviews the reported information.
In many cases involving seizure disorders, syncope, or recurrent loss of motor coordination, a 15-day direct order may be issued under N.J.A.C. 13:19-5.2.
The driver may be required to submit additional medical documentation (often Form MR-1, the Medical Examination Report) completed by their physician within 45 days. Failure to return forms on time can result in license suspension.
Approximately 55% of cases are referred to the MVC’s Medical Advisory Panel. Panel physicians review records and test results but do not examine the driver or communicate directly with them. This review usually takes 3–4 weeks.
Possible outcomes include no action, restricted driving privileges, indefinite suspension, re-examination of driving skills, or ongoing medical monitoring and reporting requirements.

The physician’s findings on the Medical Emergency Report strongly influence the next steps in the medical review process.

Related Forms and Reporting Options

Form MR-4 is specific to physician emergency reports. Other related options include:

Form MR-5 — Used by law enforcement for driver examination or medical evaluation requests.
Form MR-1 — Medical Examination Report that drivers may be required to have completed by their physician after a report is received.
Written letters from family members, social workers, or others reporting concerns about a driver’s medical fitness (anonymous reports are not accepted).

For general guidance on assessing older drivers, the American Medical Association offers resources that many New Jersey physicians find helpful.

Why Form MR-4 Matters for Road Safety in New Jersey?

Motor vehicle crashes remain a leading cause of injury-related deaths, particularly among older adults and individuals with certain medical conditions. By requiring prompt physician reporting of recurrent seizures, unconsciousness, or loss of motor coordination, New Jersey aims to identify at-risk drivers before a crash occurs.

The Medical Review Unit balances public safety with individual mobility needs. Many drivers successfully return to the road after treatment, monitoring, or the addition of appropriate restrictions. Accurate use of Form MR-4 supports this balanced approach.

Frequently Asked Questions About Form MR-4

Is Form MR-4 only for epilepsy?
No. While epilepsy is specifically mentioned, the law covers any condition causing recurrent convulsive seizures, recurrent periods of unconsciousness or impairment, or loss of motor coordination that persists or recurs despite treatment.

Can a physician report other medical conditions that affect driving?
Yes. Physicians may report any patient they believe is no longer fit to drive using Form MR-4 or by contacting the Medical Review Unit. The mandatory 24-hour requirement applies specifically to the conditions listed in N.J.S.A. 39:3-10.4.

What if I cannot download the form?
Contact the MVC Medical Review Unit at (609) 292-7500 x5032 for assistance obtaining the form or answering questions about its contents.

Where can I find official information?
Always refer to the official New Jersey Motor Vehicle Commission pages for the most current guidance:

Download New Jersey Form MR-4 Today

Physicians and medical providers should keep the current Form MR-4 readily available. Prompt, accurate reporting protects patients, their families, and everyone who shares New Jersey’s roads.

Official download link: https://www.nj.gov/mvc/pdf/violations/MVC-Form_MR-4.pdf

For questions about a specific case or the medical review process, contact the New Jersey MVC Medical Review Unit at (609) 292-7500 x5032 or by fax at (609) 292-7504.