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