Mv 80L Form PDF Details

In the realm of ensuring road safety and accommodating those with visual impairments, the MV-80L form emerges as a critical document, functioning within the New York State Department of Motor Vehicles’ Low Vision Program. This program caters to individuals whose corrected vision falls below the standard 20/40 but is not lesser than 20/70, including those who utilize telescopic lenses. As a mandatory step in the licensing process for these individuals, the form must be completed by a qualified eye care professional—either a physician, ophthalmologist, or optometrist—based on an examination conducted within the last 60 days. The MV-80L form not only establishes the medical criteria these drivers must meet but also outlines the subsequent steps needed to maintain or renew their driver's license. Failure to return this duly filled form to the Medical Review Unit can lead to suspension or the inability to renew a driver's license. Furthermore, it delineates specific standards for visual acuity and field of vision, hence setting a baseline for eligibility. While those within the program are subject to regular evaluation through the MV-80L.1 form, first-time applicants, especially telescopic lens wearers, face rigorous prerequisites, including a mandatory road test to ensure their capacity to safely operate a vehicle. It also strictly specifies that adherents are only eligible for specific classes of driver licenses and discerns the unacceptability of certain devices, like clip-on or hand-held telescopic lenses, thereby reinforcing its commitment to road safety. This comprehensive approach encapsulated within the MV-80L form reflects an essential balance between enabling individuals with visual limitations to drive while prioritizing collective roadway safety.

QuestionAnswer
Form NameMv 80L Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesMV-80L, mv80l, CDL, mv 80l form

Form Preview Example

EYE TEST REPORT FOR MEDICAL REVIEW UNIT

Medical Review Unit, Room 337

6 Empire State Plaza, Albany, NY 12228

dmv.ny.gov

LOW VISION PROGRAM - FOR PERSONS WITH CORRECTED VISION OF LESS THAN 20/40

BUT NOT LESS THAN 20/70, OR TELESCOPIC LENS WEARERS

INSTRUCTIONS:

1.If this completed form is not returned to the Medical Review Unit, you may not renew your license and you may be suspended. DO NOT GO INTO A DMV OFFICE UNTIL YOU HAVE SUBMITTED YOUR COMPLETED MV-80L TO

THE MEDICAL REVIEW UNIT AT THE ADDRESS ABOVE AND HAVE RECEIVED A RESPONSE LETTER IN THE MAIL FROM THEM.

2.The MV-80L must be completed by a physician, ophthalmologist or optometrist, and must be based on an examination performed within 60 days. PLEASE RETURN BOTH PAGES OF THE COMPLETED FORM TO THE MEDICAL REVIEW

UNIT AT THE ABOVE ADDRESS OR FAX IT TO (518) 402-2991.

3.Please note, if you are currently in the Low Vision Program, you do not need to submit form MV-80L. The Medical Review Periodic Eye Test form MV-80L.1 will be mailed to you every six or twelve months based on your eye care provider’s recommendation. If there are no changes or your license is not due to expire within the next year, you have satisfied the requirements and will not receive anything in the mail from us.

MINIMUM STANDARD FOR INDIVIDUALS WITH CORRECTED VISION OF LESS THAN 20/40, BUT NOT LESS THAN 20/70:

lHorizontal, binocular field of vision must be no less than 140 degrees.

MINIMUM STANDARD FOR TELESCOPIC LENS WEARERS:

lMust have been fitted with, trained to use, and used telescopic lenses for at least 60 days prior to filing this form.

For a first-time evaluation, telescopic lens wearers must complete the certification at the bottom of Page 2.

lClip-on or hand-held telescopic lenses are not acceptable

lVisual acuity (Snellen Method) through telescopic portion in either or both eyes must be NO LESS THAN 20/40

lVisual acuity (Snellen Method) through carrier lens in either or both eyes must be NO LESS THAN 20/100

lTotal horizontal, binocular field of vision (no field expanders) must be NO LESS THAN 140 DEGREES

lMust pass road test if he/she has not taken a road test while wearing his/her telescopic lenses

lEligible for a Class D or DJ driver license only

lIneligible for a commercial driver license (CDL), a motorcycle license or a moped license.

PATIENT — COMPLETE THIS SECTION

Name

Address

New York State Client ID #

 

Date of Birth

 

□ Male □ Female

MV-80L (1/19)

Become an Organ Donor! Visit donatelife.ny.gov

PAGE 1 OF 2
2. If telescopic lenses are used, on what date did patient receive them?

PRACTITIONER — COMPLETE THIS SECTION

Patient’s Name

 

 

 

Date of Birth

 

 

(Last)

 

(First)

 

 

(Month/Day/Year)

Date of Examination

(must be within 60 days)

Check One:

o Initial Evaluation o Re-evaluation

 

 

(Month/Day/Year)

 

 

 

 

 

1. Visual Acuity (Snellen Method) NOTE: Please check the appropriate box to identify how visual acuity was achieved, then give the visual acuity.

o With corrective lenses o Without corrective lenses o With telescopic lenses only

Right eye 20/

 

and/or left eye 20/

 

 

 

Both 20/

 

 

 

Through telescopic lenses right eye 20/

 

 

 

and/or left eye 20/

 

 

 

 

 

 

 

 

 

 

 

Through carrier lenses right eye 20/

 

and/or left eye 20/

 

 

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Does the patient meet or exceed the minimum acceptable horizontal, binocular field of vision of 140 degrees? oYes

o No

 

NOTE: The test object size for determining horizontal, binocular field of vision must be either a white 3 mm size test object at a one-half

 

meter distance, or a white 6mm size test object at a one meter distance, or the equivalent angular size for any test distance.

4.

If telescopic lenses, did the patient achieve his/her horizontal, binocular field of vision with the use of field expanders? oYes

oNo

5.What medical condition(s) caused the present loss of the patient’s visual acuity?

6. Patient should be re-evaluated every . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7. Is this condition stable at this time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

o

o

6 Months oYear

Yes o No

8.

Check restriction(s) you recommend: o Day Driving Only

o Full-View Mirror

o No Limited Access Roads

o None

9.

In your opinion, would the patient’s condition interfere with the safe operation of a motor vehicle?

o Yes

o No

 

If “Yes”, please explain in the space provided, or attach an explanation on your letterhead

 

 

 

 

 

 

 

 

 

The above information is true, complete and best reflects my professional judgement.

X

(Practitioner’s Signature)

(Date)

 

 

 

 

 

(Practitioner’s Name — please print)

(Certificate or License Number)

(

)

 

 

 

 

(Address)

(Telephone Number)

TELESCOPIC LENS WEARERS MUST COMPLETE THIS CERTIFICATION ONLY FOR A FIRST-TIME EVALUATION

I certify that I have successfully completed the minimum training requirements for telescopic lens wearers as outlined in Part 5 of the Commissioner’s Regulations, and that I received the training from:

X

( )

(Name of Trainer)

(Telephone Number)

 

 

(Address of Trainer)

 

 

 

 

 

 

 

(Signature of Patient)

 

 

(Date Training Completed)

 

 

 

 

 

 

MV-80L (1/19)

 

 

PAGE 2 OF 2

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Step 1: The initial step would be to choose the orange "Get Form Now" button.

Step 2: At the moment, it is possible to change the mv 80l. Our multifunctional toolbar enables you to include, get rid of, adjust, highlight, and undertake other sorts of commands to the content material and areas inside the document.

To be able to prepare the mv 80l PDF, enter the details for all of the parts:

portion of fields in MV-80L

Fill in the Name, Address, New York State Client ID, Date of Birth, Male Female, MVL, Become an Organ Donor Visit, and PAGE OF space using the particulars demanded by the platform.

Filling out MV-80L part 2

You can be asked for some important particulars if you would like complete the PRACTITIONER COMPLETE THIS SECTION, Patients Name, Date of Birth, Last, First, MonthDayYear, Date of Examination must be within, Check One o Initial Evaluation o, MonthDayYear, Visual Acuity Snellen Method NOTE, o With corrective lenses o Without, Right eye andor left eye Both, Through carrier lenses right eye, If telescopic lenses are used on, and If telescopic lenses did the area.

Completing MV-80L stage 3

In the section Is this condition stable at this, Check restrictions you recommend, In your opinion would the, If Yes please explain in the space, The above information is true, Practitioners Signature, Date, Practitioners Name please print, Address, Certificate or License Number, Telephone Number, TELESCOPIC LENS WEARERS MUST, and I certify that I have successfully, define the rights and responsibilities.

stage 4 to filling out MV-80L

Finish by reviewing these areas and preparing them as required: I certify that I have successfully, Name of Trainer, Telephone Number, Address of Trainer, MVL, PAGE OF, Signature of Patient, and Date Training Completed.

Entering details in MV-80L part 5

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