Mv 80L Form – Fill Out and Use This PDF

The MV 80L form is a declaration of income for the previous year. It must be filed by January 31st every year.

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Question	Answer
Form Name	Mv 80L Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	42
Avg. time to fill out	8 min 58 sec
Other names	MV-80L, CDL, form mv 80l, New_York

12

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:

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

MINIMUM STANDARD FOR TELESCOPIC LENS WEARERS:

•Must 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.

•Clip-on or hand-held telescopic lenses are not acceptable

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

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

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

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

•Eligible for a Class D or DJ driver license only

•Ineligible 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

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/

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

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

How to Edit Mv 80L Form Online for Free

The PDF editor that you're going to make use of was created by our top level computer programmers. You can prepare the 6mm file easily and conveniently applying our software. Simply stick to this particular procedure to get going.

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 6mm. 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 6, mm PDF, enter the details for all of the parts:

portion of fields in Snellen

Fill in the Name, Address, New, York, State, Client, ID DateofBirth, Male, Female MV, L and PAGE, OF space using the particulars demanded by the platform.

Filling out Snellen part 2

You can be asked for some important particulars if you would like complete the PRACTITIONER, COMPLETE, THIS, SECTION Patients, Name DateofBirth, Last, First, Month, Day, Year Date, of, Examination, must, be, within, days Month, Day, Year and Right, eye, and, or, left, eye, Both area.

Completing Snellen stage 3

In the section Practitioners, Signature Date, Practitioners, Name, please, print and Certificate, or, License, Number define the rights and responsibilities.

stage 4 to filling out Snellen

Finish by reviewing these areas and preparing them as required: Name, of, Trainer Telephone, Number Address, of, Trainer MV, L PAGE, OF Signature, of, Patient and Date, Training, Completed

Entering details in Snellen part 5

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Step 4: Create duplicates of your form. This is going to prevent possible future problems. We do not view or reveal your data, thus feel comfortable knowing it's going to be protected.

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