Illinois SOS Form DAH IH 84 Medical Verification

Illinois SOS Form DAH IH 84 Medical Verification – If you are seeking a Restricted Driving Permit (RDP) or reinstatement of driving privileges in Illinois after a suspension or revocation, you may need to document medical or treatment-related travel needs. The official form for this purpose is the Medical/Treatment Verification Form (DAH IH 84), issued by the Illinois Secretary of State Department of Administrative Hearings.

This guide explains what the form is, who needs it, how to complete it correctly, where to submit it, and how it fits into the broader process of restoring driving privileges in Illinois. All information is based on current official publications from the Illinois Secretary of State.

What Is the DAH IH 84 Medical/Treatment Verification Form?

Form DAH IH 84 is an official Illinois Secretary of State document used to verify that a petitioner (or a family member) requires regular medical appointments, counseling, or treatment. It also confirms whether the petitioner needs to fill prescriptions on a regular basis for themselves or a family member.

The form helps the Department of Administrative Hearings evaluate whether a Restricted Driving Permit should include authorization for travel to medical or treatment locations. It is one of several verification forms (alongside employment, education, and day-care forms) that support hardship driving requests.

The current version of the form is labeled “March 2026 — 1 — DAH IH 84.2 ADA” and is available as a fillable PDF.

Who Needs to Submit Form DAH IH 84?

You typically need this form if:

  • You are petitioning for a Restricted Driving Permit and want authorization to drive to medical appointments, counseling sessions, or treatment facilities.
  • You or a family member must attend regular medical or treatment meetings that require driving.
  • It is medically necessary for you to fill prescriptions regularly for yourself or a family member.

This form is distinct from the Illinois Petitioner Treatment Verification (DAH H 68), which documents completion of substance-abuse treatment recommended after a DUI evaluation. DAH IH 84 focuses on ongoing medical or treatment travel needs rather than past treatment completion.

Always check the specific requirements listed in your Notice of Hearing or the official Alcohol- and Drug-Related Hearings page, as individual cases can vary.

How to Complete the Medical/Treatment Verification Form?

The form has two main sections:

Section completed by the Petitioner

  • Petitioner’s full name and Illinois driver’s license number.
  • Indication of whether the meetings/appointments are for the applicant/petitioner or a family member (include relationship if applicable).
  • Name of the office, clinic, or hospital, plus the number of miles from the petitioner’s home.
  • Full address of the facility (street, city, state, ZIP).
  • Answer to the question: “Is it medically necessary for the applicant to fill prescription(s) for her/himself or family member on a regular basis?” (Yes or No).
  • Agreement to notify the Secretary of State’s office if involvement in counseling or medical treatment is terminated.

Section completed by the Physician’s Office or Counselor

  • Printed name of the medical professional or counselor.
  • Signature.
  • Position/title.
  • Business phone number.
  • Date of completion.

All statements are made under affirmation that the information is true and correct. Incomplete or unsigned forms are typically rejected.

Download the Official DAH IH 84 Form

Download the current fillable PDF directly from the Illinois Secretary of State website:

Download Illinois DAH IH 84 Medical/Treatment Verification Form (PDF)

For best results, download the form to your computer and open it with Adobe Acrobat Reader. Forms should not be filled out directly in a web browser.

You can also find the form listed under Administrative Hearings Publications and Forms on the official Illinois Secretary of State publications page.

Where to Mail the Completed Form?

Mail the completed and signed form to:

Secretary of State
Department of Administrative Hearings
2701 S. Dirksen Parkway, Room 220
Springfield, IL 62723

Phone: 800-252-8980 or 217-782-7065
Website: ilsos.gov

Submit the form with your other hearing documents according to the instructions in your hearing notice. Keep a copy for your records.

Tips for a Successful Submission

  • Ensure the physician or counselor completes and signs their section. Petitioner-only signatures are insufficient.
  • Provide accurate mileage and full facility address — these details help the hearing officer assess the necessity of driving privileges.
  • If treatment ends, notify the Secretary of State promptly as required by the form.
  • Combine this form with other required verification documents (employment, education, day care, etc.) when requesting a multi-purpose RDP.
  • Review the official Administrative Hearings home page for current hearing requirements, locations, and contact information.

Related Illinois Secretary of State Forms

Other common verification forms used in Administrative Hearings include:

  • Day Care Verification Form (DAH IH 81)
  • Education Verification Form (DAH IH 83)
  • Employment or Self-Employment Verification Form (DAH IH 89)
  • Illinois Petitioner Treatment Verification (DAH H 68) — for substance-abuse treatment completion
  • Medical Cannabis Verification Form (DAH H 99)

All current forms are available on the Administrative Hearings Publications and Forms page.

Additional Resources and Official Contact Information

For the most accurate and up-to-date guidance:

Springfield Flagship Office
2701 S. Dirksen Parkway
Springfield, IL 62723
Hours: Monday–Friday, 8 a.m.–4:30 p.m.

Always rely on official Illinois Secretary of State sources. Requirements can change, and individual hearing officers may request additional documentation based on your specific driving record and circumstances.

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