INSTRUCTIONS: CONNECTICUT COPY RECORDS REQUEST (Form J-23)

To request copies of records maintained by the Connecticut Department of Motor Vehicles, use a form J-23. This document can be obtained from the website of the government of the state of Connecticut.

Connecticut Copy Records Request J-23 Step 1: The first three forms listed are license records. Check the box next to any such records you wish to receive copies of. 

Connecticut Copy Records Request J-23 Step 2: The next four forms listed are registration records. Check the box next to any such records you wish to receive copies of.

Connecticut Copy Records Request J-23 Step 3: If you wish to make a miscellaneous request, check the box where indicated.

Connecticut Copy Records Request J-23 Step 4: If filing multiple requests, check the box where indicated. A separate sheet must be attached for each request.

Connecticut Copy Records Request J-23 Step 5: Read the instructions on the second page and specify your code number where indicated.

Connecticut Copy Records Request J-23 Step 6: The applicant should sign and print their name in the next two blank boxes and enter the date in the blank box after this.

Connecticut Copy Records Request J-23 Step 7: Section 1 must be completed if requesting any license records. Enter the driver's name and license number in the first two blank boxes of this section.

Connecticut Copy Records Request J-23 Step 8: Enter the driver's address and date of birth in the next two blank boxes.

Connecticut Copy Records Request J-23 Step 9: Sections 2 and 3 must be completed if requesting registration records. Enter the owner's last name, first name and middle initial in the first blank box.

Connecticut Copy Records Request J-23 Step 10: Enter the owner's street address, city or town, state and zip code in the next blank box.

Connecticut Copy Records Request J-23 Step 11: In the next blank box, enter the vehicle identification number.

Connecticut Copy Records Request J-23 Step 12: In the next four blank boxes, enter the vehicle make, year, registration plate number and the date as of which this has been the plate number.

Connecticut Copy Records Request J-23 Step 13: If filing a miscellaneous request, specify in Section 4.

Connecticut Copy Records Request J-23 Step 14: Calculate the total fee owed as instructed.

INSTRUCTIONS: CONNECTICUT DIABETES MEDICAL REPORT (Form P-142D)

When a Connecticut driver is involved in an incident that may be related to diabetes, they may be required to undergo an exam by a medical professional. The results of this examination are documented on a form P-142D. This document can be obtained from the website of the government of Connecticut.

Connecticut Diabetes Medical Report P-142D Step 1: Enter the date of the incident being addressed in the top right hand corner.

Connecticut Diabetes Medical Report P-142D Step 2: In the first two blank boxes, the patient should enter their signature and the date. The form should then be submitted to the medical professional performing the examination, who will complete the remainder.

Connecticut Diabetes Medical Report P-142D Step 3: Enter the patient's last name, first name and middle initial in the third blank box.

Connecticut Diabetes Medical Report P-142D Step 4: Enter the patient's date of birth in the fourth blank box.

Connecticut Diabetes Medical Report P-142D Step 5: Enter the patient's telephone number in the fifth blank box.

Connecticut Diabetes Medical Report P-142D Step 6: Enter the patient's street address, city, state and zip code in the sixth blank box.

Connecticut Diabetes Medical Report P-142D Step 7: Enter the date on which the onset of diabetes was documented in the seventh blank box.

Connecticut Diabetes Medical Report P-142D Step 8: In the eight blank box, enter the amount of time you have been treating this patient for diabetes.

Connecticut Diabetes Medical Report P-142D Step 9: In the ninth blank box, enter how often you see this patient regarding diabetes.

Connecticut Diabetes Medical Report P-142D Step 10: In the tenth blank box, enter the date of the last examination.

Connecticut Diabetes Medical Report P-142D Step 11: The next section concerns current therapy. Answer all questions as directed.

Connecticut Diabetes Medical Report P-142D Step 12: The next section requires you to document associated clinical phenomena by checking "yes" or "no" in the appropriate column in response to each question and providing all supplemental information requested.

Connecticut Diabetes Medical Report P-142D Step 13: Answer all remaining questions by checking "yes" or "no" and providing all supplemental information requested.

Connecticut Diabetes Medical Report P-142D Step 14: Print and sign your name and provide all identifying information requested at the bottom of the form.

INSTRUCTIONS: CONNECTICUT REQUEST FOR ADMINISTRATIVE REVIEW (Form B-360)

To request an administrative review of an application filed with the Connecticut Department of Motor Vehicles, file a form B-360. This document can be obtained from the website of the government of the state of Connecticut.

Connecticut Request For Administrative Review B-360 Step 1: Check the first box if requesting a review of a motor vehicle registration application.

Connecticut Request For Administrative Review B-360 Step 2: Check the second box if requesting a review of an application for an operator's license.

Connecticut Request For Administrative Review B-360 Step 3: Check the third box if requesting a review of an application for a CDL operators license.

Connecticut Request For Administrative Review B-360 Step 4: Check the fourth box if requesting a review of another type of application and specify.

Connecticut Request For Administrative Review B-360 Step 5: On the first blank line, enter your full name. Print or type all responses in this section of the form.

Connecticut Request For Administrative Review B-360 Step 6: On the second blank line, enter your street address, city, state and zip code.

Connecticut Request For Administrative Review B-360 Step 7: On the third blank line, enter your telephone number, including the area code.

Connecticut Request For Administrative Review B-360 Step 8: On the fourth blank line, enter your hours of contact at this telephone number.

Connecticut Request For Administrative Review B-360 Step 9: On the fifth blank line, enter your email address.

Connecticut Request For Administrative Review B-360 Step 10: On the sixth blank line, state the reason for your request.

Connecticut Request For Administrative Review B-360 Step 11: In the space provided, provide an explanation of the justification for your request.

Connecticut Request For Administrative Review B-360 Step 12: In the space provided, list the support documents submitted.

Connecticut Request For Administrative Review B-360 Step 13: On the next blank line, enter the date.

Connecticut Request For Administrative Review B-360 Step 14: On the next blank line, enter your signature.

Connecticut Request For Administrative Review B-360 Step 15: Mail the completed document, along with supporting documentation, to the address given at the bottom of the page. Alternately, you may submit these papers via fax to the number also given at the bottom of the page.

INSTRUCTIONS: ALABAMA OFFICE-BASED SURGERY ADVERSE EVENT REPORT FORM

Following an office-based surgery in Alabama which results in an adverse event, the report form discussed in this article should be filed. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Office-Based Surgery Adverse Event Report Form Step 1: Enter your name on the first blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 2: Enter your Alabama license number on the second blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 3: Enter your street address, city, state and zip code on the third blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 4: Enter your specialty as a physician on the fourth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 5: Enter the date of surgery on the fifth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 6: Enter the type of surgery on the sixth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 7: Enter the type of anesthesia used on the seventh blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 8: Enter the name and title of the person administering anesthesia on the eight blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 9: Enter the date of the adverse event on the ninth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 10: Enter the type of adverse event on the tenth blank line.

Alabama Office-Based Surgery Adverse Event Report Form Step 11: Indicate whether the patient was hospitalized with a check mark.

Alabama Office-Based Surgery Adverse Event Report Form Step 12: Indicate whether the patient experienced a full recovery, disability, death or whether the outcome is pending with a check mark.

Alabama Office-Based Surgery Adverse Event Report Form Step 13: In the blank space provided, enter a brief narrative description of what occurred during this event and any changes in office protocol that have been implemented to prevent a repetition of this event. Attach additional sheets if necessary.

Alabama Office-Based Surgery Adverse Event Report Form Step 14: Enter your signature on the next blank line and the date on the last blank line. File the form by emailing it to the address given at the bottom of the page or mailing it to the address given at the top of the page.

INSTRUCTIONS: APPLICATION FOR REPLACEMENT/WALL CERTIFICATE ALABAMA MEDICAL LICENSE

To apply for a new or replacement wall certificate documenting your Alabama medical license, file the form discussed in this article. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners & Medical Licensure Commission of Alabama.

Application For Replacement/Wall Certificate Alabama Medical License Step 1: Enter your license number on the first blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 2: Enter your name on the second blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 3: Enter your mailing street address on the third blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 4: Enter your city on the fourth blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 5: Enter your state on the fifth blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 6: Enter your zip code on the sixth blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 7: Check the first statement if your license was lost.

Application For Replacement/Wall Certificate Alabama Medical License Step 8: Check the second statement if your license was destroyed. 

Application For Replacement/Wall Certificate Alabama Medical License Step 9: Regardless of whether your license was lost or destroyed, a notarized affidavit documenting how and when your license was lost or destroyed must be attached.

Application For Replacement/Wall Certificate Alabama Medical License Step 10: Check the third statement if you require a replacement wall certificate due to a name change.

Application For Replacement/Wall Certificate Alabama Medical License Step 11: If requesting a replacement wall certificate due to a name change, give the reason for this change on the next blank line. A copy of the legal document verifying the name change must be submitted with your application.

Application For Replacement/Wall Certificate Alabama Medical License Step 12: Enter your signature on the next blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 13: Enter the date on the next blank line.

Application For Replacement/Wall Certificate Alabama Medical License Step 14: Submit the application to the address given at the bottom of the page, along with your affidavit. Additionally, you must enclose payment for the fee for this service, which is $25.