Form MV-619 at a glance
What it is: The Vision Test Report, MV-619: only a licensed physician, physician assistant, registered nurse, nurse practitioner, optician, optometrist, ophthalmologist, or supervised staff of any of these providers can complete it.
Where and when to file: Provider instructions: do not mail this report. Give it to the patient.
A filled-in Form MV-619 example: a vision test for a license renewal
How to fill out Form MV-619, box by box
Patient's name and date of birth
In Box 1, write the Patient's Name exactly as it appears on the patient's driver license: Last, First and MI.
In Box 2, enter the Date of Birth as MM/DD/YY.
Patient's street address
In Box 3, write the Patient's Street Address and Apt. #, then the City, State (If in U.S.), Country and Zip Code.
Date of examination
In Box 4, enter the Date of Examination as MM/DD/YY.
Snellen Test score and corrective lenses
In Box 5, mark YES or NO: did the patient achieve a Snellen Test score of 20/40 or better with one or both eyes? If NO, complete form MV-80L.
In Box 6, mark YES or NO: did the patient wear corrective lenses during the test?
Use this form only for patients who have a minimum Snellen Test score of 20/40 with one or both eyes, with or without corrective lenses. For patients whose best corrected vision is less than 20/40 but not less than 20/70, and for patients who wear telescopic lenses, complete form MV-80L (dmv.ny.gov/forms) and mail it to the address on that form.
Provider's name and street address
In Box 7, write the Name and Title of Provider.
In Box 8, write the Provider's Street Address, then the City, State (If in U.S.), Country and Zip Code.
Report valid for up to 12 months or 6 months
In Box 9, mark that this report is valid for up to 12 months or 6 months from the date of examination.
Professional license number and provider's signature
In Box 11, write the Professional License No.
Box 10: I have examined the patient described above, and have accurately reported my findings from that examination on this form. Sign under Provider's Signature (Sign name in Full).
More rules for Form MV-619
You may renew online, by mail, or in person at your DMV office.
PRINT in ink or TYPE all information on the form except the signature.
To enroll in DMV's Vision Registry, please visit dmv.ny.gov/visionprovide.htm. It's simple, easy and free!
If your situation is different
Renewal online or by mail
Renewal online or by mail: find a provider in DMV's Vision Registry at dmv.ny.gov/vision-registry-locator. If one of these providers completes your required vision test, you do not need this form to renew your driver license.
If your provider is not enrolled in DMV's Vision Registry, this report must be completed and used when renewing your license at dmv.ny.gov or by mail.
Renewal at a DMV office
For no additional charge, your vision test can be completed at a DMV office.
If a client renews their license at a DMV office, DMV staff are trained to administer the eye test.
Sources
[1] Form MV-619 (5/22), Vision Test Report, New York State Department of Motor Vehicles (the Official source link on this page).
