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:
Cardiac Condition
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 cardio logical consult due to his/her evaluation.
☐Stents
☐MI
☐Heart Failure
☐Exercise Testing
☐Angina
☐Pacemaker
☐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 cardio logical examination and
assessment:
☐ Date of Last Visit
☐ Tolerated Medications
☐ Is Asymptomatic
☐ Has A Satisfactory Exercises Tolerance Test (ETT)**
☐ Has A Resting Left Ventricular Ejection Fraction (LVEF) Greater than or Equal to
40%**
☐ Has No Electrocardiogram Ischemic Changes**
☐ Months or Weeks Since Event
☐ Anigina
☐ Angina at Rest
☐ Change in Angina Pattern within 3 Months of Exam
☐ Abnormal ETT
☐ Ischemic Changes on Rest ECG
☐ Intolerance to Cardiovascular TX
☐ Annual Physical Date
☐ Biennial ETT required at a Minimum, Date and Last ETT
☐ If the Abnormal or Inconclusive ETT, Imaging Stress Test Date and Results if
Indicated
**NOTE: For an initial certification following an MI, an in-hospital post-MI
echocardiogram showing an LVEF greater than or equal to 40% is sufficient.
If patient has PCI stents, please have the below listed in chart notes of your cardio
logical examination and assessment:
☐ At Least One Week After Procedure
☐ Tolerance to Medications
☐ ETT 3 to 6 Months after PCI
In these situations, the patient may not be cleared:
-Incomplete healing or Complications at Vascular Access Site
-Rest Angina
-Ischemic ECG Change
If patient has congestive heart failure, please have the below listed in chart notes of
your cardio logical examination and assessment:
☐ Date of Last Visit
☐ Results of Most Recent Echocardiogram or Other Testing of Left Ventricular
Ejection Fraction**
☐ Implantable Defibrillator
☐ Concentration
**An ejection fraction of 40% or greater is required for certification
Patients with implantable defibrillators are automatically disqualified from obtaining
medical certification for CDL license. Please call our office and let us know if your
patient has an implantable defibrillator.
If patient has a pacemaker, please have the below listed in chart notes of your cardio
logical examination and assessment:
☐ Date of Last Visit
☐ Documentation of Annual Pacemaker Check
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 checklist on you letterhead/notes 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