Mv 619 Form – Fill Out and Use

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.

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