Detroit Lakes 1361 Wenner Road Detroit Lakes, MN 56501 (218) 846-9981 Moorhead North Fargo 720 Main Ave 1100 19th Ave N, Suite M Moorhead, MN 56560 Fargo, ND 58102 (218) 359-0399 (701) 356-1150 Osgood-Fargo 4622 40th Ave S Fargo, ND 58104 (701) 364-2909 South Fargo 1517 32nd Ave S Fargo, ND 58103 (701) 232-6211 Department of Transportation (DOT) CME Letter regarding: Diabetes Effective May 21st, 2014, Commercial Driver’s License (CDL) or DOT physicals can only be done by providers who have completed training and testing to be a Certified Medical Examiner (CME). CMEs are responsible for determining medical fitness for duty, not diagnosing and treating medical conditions. Diagnosing and treating medical conditions is the responsibility of the driver and his/her primary care provider (PCP). National criteria are in place for who can and cannot drive, and in order to be considered for certification, the following patient will require additional information from his/her PCP to continue the DOT certification process. Patient Name Patient DOB 7-Day CME Date of Service for DOT Evaluation Pt. PCP/Specialist Because of the indicated underlying health conditions, new regulations make it imperative that the patient receives a medical provider consult due to his/her DOT examination. ☐Diabetes ☐Other:__________________________________ The consult must contain certain tests and opinions. There is a checklist of information our CMEs will need to know attached. Please complete this form and return with additional requested information to your patient AND our office at your earliest convenience. 7-Day Clinic DOT Consult Information 1100 19th Ave N, Suite M Fargo, ND 58102 Fax (701) 364- 9346 ATTN: DOT Consult Information Here is the information needed from SPECIALIST and/or PCP and returned to the patient and 7 Day Clinic CME on PCP or Specialist’s letterhead/ notes. Patient Name and Date of Birth Patient Diagnosis Patient Medication List Please have the below listed in chart notes of your examination and assessment: ☐Date of Last Visit ☐ Diet Controlled ☐ Tolerates Medication ☐ Insulin (Type and Dosage) ☐ Complications (Please include a list) ☐ Any Changes in Medication or Treatment Plans over the Last 12 Months (Include explanation) ☐ Blood Sugar FBS Lof for 1 Month Reviewed* ☐ HgA1c Results (Most Recent) ☐ Any Hypoglycemic Episodes in Last 12 Months requiring Medical Intervention (If yes, explain in a separate document of severity, treatment required and frequency) With any of these items, please make sure to include all test results in your notes to our CMEs. If you have any other concerns about the patient or feel as if the patient should not be cleared, please record it in the examination/assessment notes or on your personal letter head. Thank you so much for your assistance with your patient obtaining a CDL license. Please complete this form on you letterhead and return with additional requested information to your patient AND our office at your earliest convenience. 7-Day Clinic DOT Consult Information 1100 19th Ave N, Suite M Fargo, ND 58102 Fax (701) 364- 9346 ATTN: DOT Consult Information