Mv 619 Form PDF Details

Mv 619 form, also known as the "Notice of Proposed Action," is a document used by government agencies to inform citizens of proposed actions that may impact them. The form is typically filled out by agency employees and then sent to affected citizens or their representatives. It can be a helpful tool for keeping people informed about what their government is doing, and it can also provide an opportunity for citizens to provide input on proposed actions.

Here is some data that will help you find out the time it's going to take to finalize the mv 619 form.

QuestionAnswer
Form NameMv 619 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameseye exam form for new york, dmv eye test form, mv619 form, vision test report dmv

Form Preview Example

u From Upstate New York (all other area codes) (518) 486-9786 u From out of New York State: (518) 473-5595
u TDD: 1-800-368-1186 from anywhere in New York

MV-619 (3/13)

NewYorkStateDepartmentofMotorVehicles

VISION TEST REPORT

TO THE DRIVER LICENSE CUSTOMER: To improve customer service, some vision test providers have enrolled in DMV’s Vision Registry, which enables them to submit vision test results to DMV electronically. A list of providers who are enrolled in DMV’s Vision Registrycanbefoundatdmv.ny.gov/licrenew.Ifyouvisitoneofthoseprovidersforyourrequiredvisiontest,youdonothavetousethisform to apply for or renew your license, including when you renew by mail or online. However, your provider may choose to complete this report. ThisreportmustbecompletedifyouuseaproviderwhoisnotinDMV’sVisionRegistry.ToavoidatriptoDMV,youcanmailthecompleted reportwithyourlicenserenewalapplication(formMV-2)oruseitifyourenewyourlicenseatdmv.ny.gov/licrenew.

TO THE PROVIDER: ThisformshouldbeusedonlyforpatientswhoareabletoachieveaminimumSnellenTestscoreof20/40withoneor both eyes, with or without the use of corrective lenses (refer to “NOTE” at the bottom of this page). Vision test results can be entered on this form by a licensed physician, physician’s assistant, registered nurse, nurse practitioner, optician, optometrist, ophthalmologist, or supervised staffofanyoftheseproviders.ToenrollinDMV’sVisionRegistry,pleasevisitdmv.ny.gov/visionprovide.htm.

INSTRUCTIONS FOR THE PROVIDER:

Important: Pharmacists and organizations authorized by DMV to conduct tests MUST NOT use this form

1.PRINTininkorTYPEallinformationbelow(exceptforsignatures).

2.Besuretoenterthepatient’snameexactlyasitappearsonthedriverlicense.

3.Havethepatientsignhis/herfullnameinboxnumber8.

4.Inmostsituations,thisreportisvalidfor12monthsfromthedateofexamination. However,basedontheresultsofthetestandonan optometrist’sorophthalmologist’sassessmentofthepatient’svisualhealth,thepersonwhoadministersthetestcanspecifythatthis reportbevalidonlyfor6monthsfromthedateoftheexamination.Theappropriateboxinnumber11mustbechecked.

5.Signyournameinfull,andprovideyourprofessionallicensenumber,inboxnumber12.

6.Givethisreporttothepatient.Donotmailthisreport.

1. Patient’s Last Name

First

M.I.

2. Date of Birth (MO./DAY/YR.)

/ /

3.Sex

M F

4.

Patient’sAddress

 

 

 

Apt. #

 

(Number and Street)

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

 

 

 

 

 

5.

Optometrist or Ophthalmologist only. Best Vision Test Score (Snellen) with or without corrective lenses.

6. Date of Examination

 

Right

Left

Both

(MO./DAY/YR.)

/

 

 

 

 

/

7.

Did the patient wear corrective lenses to achieve a Snellen Test score of 20/40 with one or both eyes?

 

 

 

YES

NO

 

 

 

8.Patient’s Signature (Sign Name in Full)

Sign Here __________________________________________________________________________________________________________________________

Ihaveexaminedthepatientdescribedabove,andhaveaccuratelyreportedmyfindingsfromthatexaminationonthisform.

9.

Name and Title

 

 

 

of Provider

 

 

 

 

 

 

10.

Provider’s Address

 

 

 

(Number and Street)

 

 

 

 

 

 

 

City

State

Zip Code

 

 

11.Optometrist or Ophthalmologist only. This report is valid for up to (check one)

12months 6months from the date of examination.

 

 

 

12.Provider’s Signature (Sign Name in Full)

 

Professional

 

Sign Here________________________________________________________________________________

License.

 

No. ____________________________________

 

 

 

 

NOTE: 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 and mail it to the address on that form. The MV-80L can be downloaded from the DMV website at www.dmv.ny.gov/forms/mv80L.pdf or by calling:

u Metropolitan New York City

From the 212, 347, 646, 718, 917 or 929 area codes:

(212)645-5550or(718)966-6155

u From the 516, 631, 845, 914 area codes:(718) 477-4820

www.dmv.ny.gov

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