Government of Ontario

Licence Appeal Tribunal

530 – 20 Dundas Street West
Toronto ON M5G 2C2
Phone: 416 314-4260
Toll Free: 1 800 255-2214
Fax: 416 314-4270
Toll Free: 1 800 720-5292

Supporting Documentation – Administrative Driver's Licence Suspension – Applicant's Medical Information

Under s.48.3 and s. 50.1 of the Highway Traffic Act

IMPORTANT INFORMATION FOR THE APPLICANT:

Only submit this information with your Administrative Driver's Licence Suspension appeal if you are appealing on the ground that you were unable to comply with a demand made under section 254 of the Criminal Code (Canada) for a medical reason.
Ask you doctor to complete all sections of the form and return it to you.
Attach this completed form to your 'Notice of Appeal' and submit to the Tribunal.

IMPORTANT INFORMATION FOR THE DOCTOR:

Your patient (the Applicant) has appealed a 90-day Administrative Driver's Licence Suspension imposed under s.48.3 of the Highway Traffic Act.
The Applicant has appealed on the ground that there was a medical reason why they were unable to comply with the demand made under s.254 of the Criminal Code (Canada) by a police officer.
Rule 15.3 of the Tribunal’s Rules of Practice requires the Applicant to submit the information requested in this form as part of their appeal.
Complete all sections of this form and return it to the Applicant.

Tribunal File Number (if any):

Applicant Name and Contact Information:

Last Name
First Name
Middle Initial

Address

Unit No.
Street No.
Street Name
City
Province
Postal Code
Telephone No.
Fax No.

Details and diagnosis of patient's condition related to this appeal.

History of condition precluding patient from complying with demand made under section 254 of the Criminal Code (Canada).

Type of measurements or recent tests taken including dates.

Relevant details of last visit, including date of patient's last visit.

How long has the applicant been your patient? Years or Months.

Physician's information:

Last Name
First Name
Middle Initial
Date of Birth (yyyy/mm/dd)
Type of practice or specialized field (indicate specialty)

Address

Unit No.
Street No.
Street Name
City
Province
Postal Code

Physician's Signature

Date (yyyy/mm/dd)

The Licence Appeal Tribunal collects the personal information requested on this form under section 3 of the Licence Appeal Tribunal Act, 1999. This information will be used to determine applications under this Act. After an application is filed, all information may become available to the public. Any questions about this collection may be directed to the Licence Appeal Tribunal at 416 314-4260 or toll-free at 1 800 255-2214.

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