The MV-80U.1 form serves as a vital conduit between medical professionals and the New York State Department of Motor Vehicles' Medical Review Unit, ensuring that individuals with medical, physical, mental conditions, or a combination thereof are accurately assessed for their capability to operate a motor vehicle safely. This document mandates the completion by a licensed physician or nurse practitioner following an examination conducted within the last 120 days from the submission date, emphasizing the paramount importance of current, comprehensive medical evaluation in the decision-making process. The form is meticulously designed to capture detailed information regarding the driver's medical condition(s), including the type of health care provider overseeing the treatment, specifics about the diagnosed conditions, symptoms, and the impact these may have on the patient's driving abilities. It goes further to inquire about any medical tests conducted, current treatments, and medications, providing a holistic view of the individual's health status. Additionally, the physician or nurse practitioner's professional judgment about the patient's fitness to drive plays a crucial role, potentially leading to a request for further evaluation by the Department. Owing to the stringent requirement for information only from qualified health professionals, the MV-80U.1 form embodies a critical step in safeguarding public safety on the roads while respecting the rights and needs of drivers facing medical challenges.
| Question | Answer |
|---|---|
| Form Name | Form Mv 80U 1 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Alzheimers, neuromuscular, nystatedmv, MRI |
NewYorkStateDepartmentofMotorVehicles
PHYSICIAN’S STATEMENT FOR MEDICAL REVIEW UNIT
ToOurDriverLicenseCustomer:
Usethisformtoreportmedical,physical,mentaloracombinationofsuchconditionstothe Medical ReviewUnit. Pleasecompletethe informationbelowandhaveyourphysician/nursepractitionercompletethe statementonPage 2.
IMPORTANT: The information provided must be based on a current examination performed by your physician/nurse practitioner within the last 120 days from the date this statement is submitted.
NOTE: Information provided by a physician assistant or emergency care personnel is NOT acceptable. After review of the completed statement you may be requested to provide additional information from either the physician/nurse practitioner who provided the information or from a qualified specialist.
PLEASEPRINTORTYPE
Last Name |
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First Name |
M.I. |
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Date of Birth (Month/Day/Year) |
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Mailing Address (Number and Street) |
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Client ID No. (Driver License No.) |
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Any other names that you have used (if applicable) |
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Daytime Telephone Number (Area Code) |
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Iambeingtreatedand/orhave beentreatedforthefollowingmedical,physical,ormental condition(s):
______________________________________________________________________________________________________________
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Pleasecheckthe appropriatebox(es)belowandfillinyourphysician/nursepractitioner’sname:
Iambeingtreatedprimarilybymyprimarycarephysician,Dr._____________________________________________.
Iambeingtreatedprimarilybymynursepractitioner, N.P._______________________________________________.
Iambeingtreatedbymyspecialist,Dr._______________________________________________.
Iambeingtreatedbymypsychiatrist/psychologist,Dr.___________________________________________.
Please have your physician/nurse practitioner complete page 2, and then return this form to:
MedicalReviewUnit
DriverImprovementBureau
NYSDepartmentofMotorVehicles
6EmpireState Plaza
Albany,NY12228
Visit us at: www.dmv.ny.gov |
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THIS SIDE IS TO BE COMPLETED BY YOUR PHYSICIAN/NURSE PRACTITIONER
Physician/Nurse Practitioner: Please attach a sample of your letterhead or a voided prescription blank.
PLEASEPRINTORTYPE
Patient’s Last Name |
First Name |
M.I. |
Date of Birth (Month/Day/Year)
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ExaminationDate(must bewithin 120 daysfromthedatethisformissubmitted): |
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Conditionpatientisbeingtreatedfor: |
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Epilepsy/convulsivedisorder |
Syncope/fainting/dizzinessor |
Diabetes |
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Sleepdisorder |
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Dementia/senility/Alzheimer’s |
a conditionthatcausesunconsciousness |
Headtrauma/tumor |
Heartcondition |
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Stroke |
Neurologicalorneuromusculardisease |
Mental disorder |
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Other(pleasespecify)____________________________________________________________________________________
3.Symptoms,severity,andfrequencyofcondition:____________________________________________________________________
__________________________________________________________________________________________________________
4.Dateofthelastepisode/incidentassociatedwiththiscondition: ________________________________________________________
5.Haveanyepisode(s)/incident(s)associatedwiththisconditioncausedanylossofconsciousness,awareness,and/orbodycontrol?
YES NO IfYES,listthe datesofthe episode(s)/incident(s)____________________________________________________
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6.Giveabriefdescriptionregardinganyfactorsthat mayhave caused/contributedtotheepisode(s)/incident(s): __________________
__________________________________________________________________________________________________________
7.Tothebestofyourknowledgehaveanyofthepatient’sepisode(s)/incident(s)resultedinamotorvehicleaccident(s)and/orincident(s)?
YESNO IfYES,pleasegive detailsandthe datesoftheepisode(s)/incident(s)andrelatedaccident(s): __________________
__________________________________________________________________________________________________________
8.Testsconducted(e.g.,EEG,EKG,MRI,sleepstudy,serumlevels,etc.): ________________________________________________
9.Currenttreatment,medicationanddosage,and/ortherapy:____________________________________________________________
__________________________________________________________________________________________________________
ThefollowingMUSTbeansweredifthepatienthasasleep disorder:
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Date firstdiagnosedwiththesleepdisorder:___________________________ |
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Ispatientreceivingtreatment? _______ Typeoftreatment_______________________ Datetreatmentbegan:____________ |
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Ispatientcompliantwiththetreatment?_______________________________________________ |
10.Inyourmedicalopinion,atthistime,wouldthepatient’sconditioninterferewiththesafeoperationofamotorvehicle?
YES NO (If YES, please explain in the space provided or in an attached statement on your letterhead.)
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NOTE: If you answered YES to question 10, skip Question 11. |
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11. |
NO |
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IfYES,pleaseexplain: ______________________________________________________________________________________ |
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Physician/Nurse Practitioner’s Name (Pleaseprintinfull) |
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Certificate or license number and state where licensed |
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Physician/Nurse Practitioner’s Mailing Address (includenumberandstreet) |
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Telephone Number (areacode) |
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Primary care physician |
Neurologist Psychiatrist/Psychologist |
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Physician/Nurse Practitioner |
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Endocrinologist Other _________________________________ |
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Physician/Nurse Practitioner’s Signature |
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Date (Month/Day/Year) |
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(Information provided by a physician assistant or emergency care personnel is NOT acceptable.) |
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