Form Mv 80U 1 – Fill Out and Use This PDF

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		First Name	M.I.		Date of Birth (Month/Day/Year)			Male
						/	/	Female
Mailing Address (Number and Street)
City						State	Zip Code
Client ID No. (Driver License No.)		Any other names that you have used (if applicable)			Daytime Telephone Number (Area Code)
					(	)

Iambeingtreatedand/orhave beentreatedforthefollowingmedical,physical,ormental condition(s):

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Pleasecheckthe appropriatebox(es)belowandfillinyourphysician/nursepractitioner’sname:

Iambeingtreatedprimarilybymyprimarycarephysician,Dr._____________________________________________.

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

MedicalReviewUnit

DriverImprovementBureau

NYSDepartmentofMotorVehicles

6EmpireState Plaza

Albany,NY12228

(518)474-0774

MV-80U.1 (9/10)

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

1.	ExaminationDate(must bewithin 120 daysfromthedatethisformissubmitted):		/	/
2.	Conditionpatientisbeingtreatedfor:
	Epilepsy/convulsivedisorder	Syncope/fainting/dizzinessor	Diabetes		Sleepdisorder
	Dementia/senility/Alzheimer’s	a conditionthatcausesunconsciousness	Headtrauma/tumor		Heartcondition
	Stroke	Neurologicalorneuromusculardisease	Mental disorder

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)____________________________________________________

__________________________________________________________________________________________________________

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:

a.)	Date firstdiagnosedwiththesleepdisorder:___________________________
b.)	Ispatientreceivingtreatment? _______ Typeoftreatment_______________________ Datetreatmentbegan:____________
c.)	Ispatientcompliantwiththetreatment?_______________________________________________

10.Inyourmedicalopinion,atthistime,wouldthepatient’sconditioninterferewiththesafeoperationofamotorvehicle?

YES NO (If YES, please explain in the space provided or in an attached statement on your letterhead.)

	__________________________________________________________________________________________________________
	__________________________________________________________________________________________________________
	__________________________________________________________________________________________________________
	NOTE: If you answered YES to question 10, skip Question 11.
11. DoyourecommendtheDepartmentconductanon-the-roaddrivingperformanceevaluation?YES						NO
	IfYES,pleaseexplain: ______________________________________________________________________________________
	________________________________________________________________________________________________________
Physician/Nurse Practitioner’s Name (Pleaseprintinfull)				Certificate or license number and state where licensed
Physician/Nurse Practitioner’s Mailing Address (includenumberandstreet)					Telephone Number (areacode)
					(	)
City	State	Zip Code	Primary care physician			Neurologist Psychiatrist/Psychologist
			Physician/Nurse Practitioner
			Endocrinologist Other _________________________________
Physician/Nurse Practitioner’s Signature							Date (Month/Day/Year)
➧
(Information provided by a physician assistant or emergency care personnel is NOT acceptable.)							/	/

MV-80U.1 (9/10)

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