Fillable Printable Form MV-80U.1 - Physician's Statement for Medical Review Unit - New York

Form MV-80U.1 - Physician's Statement for Medical Review Unit - New York

Visit us at: www.dmv.ny.gov

To Our Driver License Customer:

Use this form to report medical, physical, mental or a combination of such conditions to the Medical Review Unit.

Please complete the information below and have your physician/physician assistant/nurse practitioner complete the statement on Page 2.

IMPORTANT: The information provided must be based on a current examination performed by your physician/physician

assistant/nurse practitioner within the last 120 days from the date this statement is submitted.

NOTE: Information provided by emergency care personnel is NOT acceptable. After review of the completed statement

you may be requested to provide additional information from either the physician/physician assistant/nurse practitioner

who provided the information or from a qualified specialist.

Last Name

Mailing Address (Number and Street)

Client ID No. (Driver License No.)

Any other names that you have used (if applicable) Daytime Telephone Number (Area Code)

( )

City

State Zip Code

First Name M.I. Date of Birth (Month/Day/Year)

/ /

o Male

o Female

I am being treated and/or have been treated for the following medical, physical, or mental condition(s):

______________________________________________________________________________________________________________

Please check the appropriate box(es) below and fill in your physician/physician assistant/nurse practitioner’s name:

o I am being treated primarily by my primary care physician, Dr. _____________________________________________.

o I am being treated primarily by my nurse practitioner, N.P. _______________________________________________.

o I am being treated primarily by my physician assistant, P.A. _____________________________________________.

o I am being treated by my specialist, Dr. _______________________________________________.

o I am being treated by my psychiatrist/psychologist, Dr. ___________________________________________.

MV-80U.1 (5/15)

PAGE 1 OF 2

Please have your physician/physician assistant/nurse practitioner complete page 2, and then return this form to:

Medical Review Unit

Driver Improvement Bureau

NYS Department of Motor Vehicles

6 Empire State Plaza

Albany, NY 12228

(518) 474-0774

PLEASE PRINT OR TYPE

PHYSICIAN’S STATEMENT FOR MEDICAL REVIEW UNIT

1. Examination Date (must be within 120 days from the date this form is submitted): _______________________

2. Condition patient is being treated for:

o Epilepsy/convulsive disorder o Syncope/fainting/dizziness or o Diabetes o Sleep disorder

o Dementia/senility/Alzheimer’s a condition that causes unconsciousness o Head trauma/tumor o Heart condition

o Stroke o Neurological or neuromuscular disease o Mental disorder

o Other (please specify) ____________________________________________________________________________________

3. Symptoms, severity, and frequency of condition:____________________________________________________________________

__________________________________________________________________________________________________________

4. Date of the last episode/incident associated with this condition: ________________________________________________________

5. Have any episode(s)/incident(s) associated with this condition caused any loss of consciousness, awareness, and/or body control?

o YES o NO If YES, list the dates of the episode(s)/incident(s) ____________________________________________________

__________________________________________________________________________________________________________

6. Give a brief description regarding any factors that may have caused/contributed to the episode(s)/incident(s): __________________

__________________________________________________________________________________________________________

7. To the best of your knowledge have any of the patient’s episode(s)/incident(s) resulted in a motor vehicle accident(s) and/or incident(s)?

o YES o NO If YES, please give details and the dates of the episode(s)/incident(s) and related accident(s): __________________

__________________________________________________________________________________________________________

8. Tests conducted (e.g., EEG, EKG, MRI, sleep study, serum levels, etc.): ________________________________________________

9. Current treatment, medication and dosage, and /or therapy: ____________________________________________________________

__________________________________________________________________________________________________________

The following MUST be answered if the patient has a sleep disorder:

a.) Date first diagnosed with the sleep disorder:___________________________

b.) Is patient receiving treatment? _______ Type of treatment _______________________ Date treatment began:____________

c.) Is patient compliant with the treatment?_______________________________________________

10. In my medical opinion, at this time (please check one):

o the patient’s condition may affect the safe operation of a motor vehicle, and the patient should be evaluated by the Department of

Motor Vehicles.

o the patient’s condition prevents the safe operation of a motor vehicle and driving privileges should be suspended.

o the patient’s condition will not interfere with the safe operation of a motor vehicle.

Please provide further detail in the space provided or in an attached statement on your letterhead:

____________________________________________________________________________________________________________

THIS SIDE IS TO BE COMPLETED BY YOUR PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER

Physician/Physician Assistant/Nurse Practitioner: Please attach a sample of your letterhead or a voided prescription blank.

PLEASE PRINT OR TYPE

Patient’s Last Name

First Name M.I.

Physician/Physician Assistant/Nurse Practitioner’s Name (Please print in full)

Physician/Physician Assistant/Nurse Practitioner’s Mailing Address (include number and street)

Physician/Physician Assistant/Nurse Practitioner’s Signature

City

Date (Month/Day/Year)

/ /

Date of Birth (Month/Day/Year)

/ /

o Male

o Female

State Zip Code

Telephone Number (area code)

( )

Certificate or license number and state where licensed

MV-80U.1 (5/15)

PAGE 2 OF 2

(Information provided by emergency care personnel is NOT acceptable.)

o Primary care physician o Neurologist o Psychiatrist/Psychologist

o Physician/Physician Assistant/Nurse Practitioner

o Endocrinologist o Other _________________________________