Fillable Printable Form MV-80L - Eye Test Report for Medical Review Unit - New York

Form MV-80L - Eye Test Report for Medical Review Unit - New York

INSTRUCTIONS:

l This questionnaire must be completed by a physician, ophthalmologist or optometrist, and must be based on an

examination performed within 60 days.

PLEASE RETURN THE COMPLETED ORIGINAL OF BOTH PAGES OF

THIS FORM TO THE MEDICAL REVIEW UNIT AT THE ADDRESS SHOWN IN THE BOX ABOVE.

l If this completed questionnaire and all related statements are not returned to the Medical Review Unit (at their

address above), your license may be suspended.

YOU MUST HAVE APPROVAL FROM THE MEDICAL REVIEW

UNIT BEFORE YOU CAN OBTAIN A VALID LICENSE. ALL MEMBERS OF THE LOW VISION PROGRAM ARE

REQUIRED TO PROVIDE AN EVALUATION STATEMENT FROM THEIR EYE CARE PROVIDER EVERY

6 MONTHS OR ONCE A YEAR, DEPENDING UPON THE RECOMMENDATION OF THE EYE CARE PROVIDER.

MINIMUM STANDARD FOR INDIVIDUALS WITH CORRECTED VISION OF LESS THAN 20/40, BUT NOT LESS

THAN 20/70:

l Horizontal, binocular field of vision must be no less than 140 degrees.

MINIMUM STANDARD FOR TELESCOPIC LENS WEARERS:

l Must have been fitted with, trained to use, and used telescopic lenses for at least 60 days prior to filing this form.

For a first-time evaluation, telescopic lens wearers must complete the certification at the bottom

of Page 2.

l Clip-on or hand-held telescopic lenses are not acceptable

l Visual acuity (Snellen Method) through telescopic portion in either or both eyes must be NO LESS THAN 20/40

l Visual acuity (Snellen Method) through carrier lens in either or both eyes must be NO LESS THAN 20/100

l Total horizontal, binocular field of vision (no field expanders) must be NO LESS THAN 140 DEGREES

l Must pass road test if he/she has not taken a road test while wearing his/her telescopic lenses

l Eligible for a Class D or DJ driver license only

l Ineligible for a commercial driver license (CDL), a motorcycle license or a moped license.

PATIENT — COMPLETE THIS SECTION

Please Print or Type

Name

__________________________________________________________________________________________________

(Last) (First) (M.I.)

Address ________________________________________________________________________________________________

(Number and Street) (Apt. No.)

____________________________________________________________________________________________________________

(City) (State) (Zip Code)

New York State Client ID # ______________________ Date of Birth __________________ o Male o Female

MV-80L (1/13)

www.dmv.ny.gov

PAGE 1 OF 2

(QUESTIONNAIRE FOR PERSONS WITH CORRECTED VISION OF LESS THAN 20/40

BUT NOT LESS THAN 20/70, OR TELESCOPIC LENS WEARERS)

EYE TEST REPORT FOR MEDICAL REVIEW UNIT

MAIL TO:

Medical Review Unit, Rm. 337

New York State

Department of Motor Vehicles

6 Empire State Plaza

Albany NY 12228

STATE OF NEW YORK

DEPARTMENT OF MOTOR VEHICLES

6 EMPIRE STATE PLAZA, ALBANY NY 12228

I certify that I have successfully completed the minimum training requirements for telescopic lens wearers as outlined in Part 5 of the

Commissioner’s Regulations, and that I received the training from:

_________________________________________________________________________ (_____)_____________________

_______________________________________________________________________________________________________

___________________________________________________________________ _________________________________

PRACTITIONER — COMPLETE THIS SECTION

TELESCOPIC LENS WEARERS MUST COMPLETE THIS CERTIFICATION ONLY FOR A FIRST-TIME EVALUATION

Date of Examination ____________________ (must be within 60 days)

Patient’s Name____________________________________________________________________ Date of Birth ____________________

Check One:

o Initial Evaluation o Re-evaluation

1. Visual Acuity (Snellen Method) NOTE: Please check the appropriate box to identify how visual acuity was achieved, then give the visual acuity.

o With corrective lenses

Right eye 20/______and/or left eye 20/______ Both 20/______

o Without corrective lenses

o With telescopic lenses only Through telescopic lenses right eye 20/______and/or left eye 20/______

Through carrier lenses right eye 20/______and/or left eye 20/______

2. If telescopic lenses are used, on what date did patient receive them? ___________________

3. Does the patient meet or exceed the minimum acceptable horizontal, binocular field of vision of 140 degrees?

o Yes o No

NOTE: The test object size for determining horizontal, binocular field of vision must be either a white 3 mm size test object at a one-half

meter distance, or a white 6mm size test object at a one meter distance, or the equivalent angular size for any test distance.

4. If telescopic lenses, did the patient achieve his/her horizontal, binocular field of vision with the use of field expanders?

o Yes o No

5. What medical condition(s) caused the present loss of the patient’s visual acuity?_________________________________________________

_________________________________________________________________________________________________________________

6. Patient should be re-evaluated every . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

o 6 Months o Year

7. Is this condition stable at this time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes o No

8. Check restriction(s) you recommend:

o Day Driving Only o Full-View Mirror o No Limited Access Roads o None

9. In your opinion, would the patient’s condition interfere with the safe operation of a motor vehicle? . . . . . . . . . . . .

o Yes o No

If “Yes”, please explain in the space provided, or attach an explanation on your letterhead_________________________________________

________________________________________________________________________________________________________________

The above information is true, complete and best reflects my professional judgement.

__________________________________________________________________ _________________________________

____________________________________________________________________ _________________________________

____________________________________________________________________ (_____)___________________________

MV-80L (1/13)

PAGE 2 OF 2

/ /

(Last) (First) (Month/Day/Year)

(Month/Day/Year)

(Practitioner’s Signature)

(Practitioner’s Name — please print) (Certificate or License Number)

(Address)

(Name of Trainer)

(Address of Trainer)

(Signature of Patient) (Date Training Completed)

(Telephone Number)

(Date)