PennDOT Form DL-104: General Psychiatric Form Guide – The Pennsylvania Department of Transportation (PennDOT) requires specific medical evaluations to ensure drivers can operate vehicles safely. One key document in this process is the PennDOT Form DL-104, also known as the General Psychiatric Form. This form helps assess whether a mental or emotional condition could affect a person’s ability to drive safely on Pennsylvania roads.
This guide explains what Form DL-104 is, when it is required, how it works, and where to download the official version. It is written for U.S. residents, particularly those in Pennsylvania, including drivers, family members, and healthcare professionals.
What Is PennDOT Form DL-104?
PennDOT Form DL-104 is the official General Psychiatric Form used by healthcare providers in Pennsylvania. It gathers detailed information about a patient’s psychiatric history, current mental health status, treatments, medications, and any symptoms that might impair safe driving.
According to Pennsylvania regulations under Title 67 of the Pennsylvania Code, Chapter 83 (Physical and Mental Criteria for Drivers), healthcare providers may use this form when evaluating conditions that could lead to disqualification from driving. These include mental disorders that cause inattentiveness, hallucinations, delusions, suicidal ideation, excessive aggressiveness, or other symptoms presenting a clear and present danger.
The form supports PennDOT’s medical reporting program, which helps keep roadways safe by identifying drivers whose medical conditions may compromise their ability to operate a motor vehicle.
Who Needs to Complete Form DL-104?
Form DL-104 is primarily completed by authorized healthcare personnel, such as physicians, psychiatrists, or other licensed professionals authorized to diagnose and treat mental health conditions. It is typically required in these situations:
- When a healthcare provider diagnoses a patient (age 15 or older) with a mental or emotional disorder that could impair driving ability.
- During the medical review process for an existing driver’s license or a new license application.
- When PennDOT requests additional psychiatric evaluation after receiving an initial medical report.
- In cases involving conditions such as severe depression, bipolar disorder, schizophrenia, or other disorders with symptoms that affect attention, judgment, or impulse control.
Drivers themselves do not usually fill out the clinical sections. The treating healthcare provider completes the medical portions and signs the form. The patient may need to provide personal information and consent.
Note: A separate version, DL-104A, exists specifically for school bus drivers under different medical standards (Chapter 71).
Key Sections of the General Psychiatric Form DL-104
While the exact layout may be updated periodically, the form generally includes the following areas based on official PennDOT medical reporting practices:
- Patient Information – Driver’s license number, full name, date of birth, address, height, sex, eye color, contact details.
- Treatment History – How long the provider has treated the patient and details of the diagnosis.
- Psychiatric Diagnosis – Specific mental or emotional disorders identified.
- Impairment Assessment – Questions about attentiveness to driving, intellectual functioning, perception, reaction time, coordination, and personality factors that could affect safety.
- Medications – Current psychiatric medications, dosages, and whether they may impact driving ability.
- Provider Information and Certification – Provider’s name, credentials, contact information, and signature confirming the accuracy of the information.
Both the healthcare provider and, in some cases, the patient must sign the form to attest that the information is complete and accurate.
When and Why Healthcare Providers Must Report Psychiatric Conditions?
Under Section 1518 of the Pennsylvania Vehicle Code, physicians and other authorized healthcare personnel must report to PennDOT, in writing within 10 days, any patient 15 years of age or older diagnosed with a condition that could impair the ability to drive safely. Reports are not required if the condition is expected to last less than 90 days.
Form DL-104 is one of the condition-specific tools available for psychiatric cases. Providers can also use the Initial Reporting Form (DL-13) or submit a detailed letter. Using the specific psychiatric form helps PennDOT make a more informed licensing decision.
Reports are confidential and used solely to determine driving qualifications. Healthcare providers receive immunity from civil and criminal liability for making required reports in good faith.
For official details on medical criteria, visit the PennDOT Medical Criteria page.
How to Download and Submit PennDOT Form DL-104
The official Form DL-104 is available as a PDF from the Commonwealth of Pennsylvania website. Healthcare providers typically need medical reporting login credentials to access many protected medical forms. Drivers or the public can often obtain the form through authorized channels or request it via PennDOT.
Official Download Link:
Download Pennsylvania PennDOT Form DL-104 – General Psychiatric Form (PDF)
Once completed, the form can generally be submitted by mail, fax, or email to:
Bureau of Driver Licensing
P.O. Box 68682
Harrisburg, PA 17106-8682
Phone: 717-787-9662 or 717-787-9664
Email: [email protected]
Always check the current instructions on the form or the official PennDOT Medical Reporting Forms page for the preferred submission method, as some forms now support secure electronic submission.
For the full list of medical reporting forms and credential requests, visit the official Medical Reporting Forms page.
What Happens After Form DL-104 Is Submitted?
After receiving a completed DL-104 or other medical report, PennDOT reviews the information. Possible outcomes include:
- No action if the condition does not impair safe driving.
- Request for additional medical information or a specialized examination.
- Placement of license restrictions.
- Recall or suspension of the driver’s license if the provider indicates the person is not qualified to drive safely.
- Referral to the Medical Advisory Board in complex cases.
Drivers have the right to due process. If a license is recalled or restricted, PennDOT notifies the individual in writing and provides information about the review or appeal process.
Helpful resources for drivers and families include PennDOT brochures on what to expect after a medical report and how to stay independent if driving is no longer possible. These are available on the PennDOT Medical Reporting Information Center.
Tips for Drivers and Families in Pennsylvania
- Be honest with your healthcare provider about symptoms that could affect driving (e.g., concentration problems, medication side effects, or suicidal thoughts).
- Understand that reporting is required by law and is intended to protect public safety—not to punish individuals with mental health conditions.
- If your license is affected, ask your provider about treatment plans, medication adjustments, or documentation that may support restoration of driving privileges later.
- Explore alternative transportation options early if driving becomes restricted.
- Contact PennDOT’s Medical Unit directly with questions about your specific case.
Frequently Asked Questions About Form DL-104
Is Form DL-104 only for new license applicants?
No. It is used for both new applicants and existing licensed drivers when a psychiatric condition is identified or reviewed.
Can I fill out the form myself?
The clinical evaluation sections must be completed by a qualified healthcare provider. Patients supply personal details and may need to sign acknowledgments.
Is there a fee for submitting Form DL-104?
There is typically no separate fee for the medical report itself. Standard license fees may still apply depending on the situation.
Where can I find more official information?
Visit the PennDOT Medical Reporting page or the Medical Reporting FAQs for the most current guidance.
Conclusion
The Pennsylvania PennDOT Form DL-104 – General Psychiatric Form plays an important role in balancing individual independence with public roadway safety. By providing structured psychiatric information, healthcare providers help PennDOT make informed decisions about driving privileges.
If you are a healthcare provider, ensure you have the proper credentials and use the most current official form. If you are a driver or family member, stay informed about the process and communicate openly with your medical team.