Mv-80L Details

Mv 80L Form is an easy to use, effective and professional form creation software. This software makes it possible for you to quickly create forms, surveys and questionnaires without any programming knowledge. Additionally, Mv 80L Form offers a wide range of templates and customization options to ensure your forms look exactly the way you want them to. So if you need a simple, reliable form creation tool, Mv 80L Form is definitely worth considering.

We have compiled some quick details about the mv 80l form. It will present you with the rough time you will need to fill out the form and a few additional details.

QuestionAnswer
Form NameMv 80L Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesNew_York, WEARERS, mv 80l ny dmv, dmv eye test form mv 80l

Form Preview Example

STATE OF NEW YORK

DEPARTMENT OF MOTOR VEHICLES

6 EMPIRE STATE PLAZA,ALBANY NY 12228

EYE TEST REPORT FOR MEDICAL REVIEW UNIT

MAIL TO:

Medical Review Unit, Rm. 337 New York State Department of Motor Vehicles 6 Empire State Plaza Albany NY 12228

(QUESTIONNAIRE FOR PERSONS WITH CORRECTED VISION OF LESS THAN 20/40

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

INSTRUCTIONS:

This questionnaire must be completed by a physician, ophthalmologist or optometrist, and must be based on an

examination performed within 60 days.PLEASE RETURN THE COMPLETED ORIGINAL OF BOTH PAGES OF

THIS FORM TO THE MEDICAL REVIEW UNITAT THEADDRESS SHOWN IN THE BOXABOVE.

If this completed questionnaireandallrelatedstatementsare not returned to the Medical Review Unit (attheir

addressabove), your license may be suspended.YOU MUST HAVEAPPROVAL FROM THE MEDICAL REVIEW

UNIT BEFORE YOU CAN OBTAINAVALID LICENSE.ALL MEMBERS OF THE LOW VISION PROGRAMARE REQUIRED TO PROVIDEAN EVALUATION STATEMENT FROM THEIR EYE CARE PROVIDER EVERY

6 MONTHS OR ONCEAYEAR, DEPENDING UPON THE RECOMMENDATION OF THE EYE CARE PROVIDER.

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 THAN20/40

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

PleasePrintorType

Name __________________________________________________________________________________________________

(Last)(First)(M.I.)

Address ________________________________________________________________________________________________

(Number and Street)

(Apt. No.)

____________________________________________________________________________________________________________

(City)

(State)

(Zip Code)

NewYork State Client ID # ______________________

Date of Birth__________________

o Male o Female

MV-80L(1/13)

www.dmv.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: oInitial Evaluation

oRe-evaluation

 

(Month/Day/Year)

 

 

 

 

 

1.

VisualAcuity(SnellenMethod)

NOTE:Pleasechecktheappropriateboxtoidentifyhowvisualacuitywasachieved,thengivethevisualacuity.

 

oWith corrective lenses

Right eye 20/______and/or left eye 20/______

Both 20/______

 

 

 

oWithout corrective lenses

 

 

 

 

 

 

 

 

 

 

oWith telescopic lenses only

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 of140 degrees? oYes

oNo

 

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 equivalentangular size for any test distance.

4.

Iftelescopiclenses,didthepatientachievehis/herhorizontal,binocularfieldofvisionwiththeuseoffieldexpanders?

oYes

oNo

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

 

_________________________________________________________________________________________________________________

6.

Patient should be re-evaluated every

. . . . . . . . . . . . . . . . . . . . .

. .. . . . . .

. . . . . . . . . o 6 Months

oYear

7.

Is this condition stable at this time?

. . . . . . . . . . . . . . . . . . . . .

. . . . . . . .

. . . . . . . . . o Yes

 

oNo

8.

Check restriction(s) you recommend: oDay Driving Only

oFull-View Mirror

oNo LimitedAccess Roads

oNone

9.

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

. . . . . . . . . o Yes

 

oNo

 

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.

 

 

 

__________________________________________________________________

_________________________________

 

(Practitioner’s Signature)

 

 

(Date)

 

 

____________________________________________________________________

_________________________________

 

(Practitioner’s Name — pleaseprint)

 

 

(Certificate or License Number)

 

____________________________________________________________________ (_____)___________________________

(Address)

(Telephone Number)

TELESCOPIC LENS WEARERS MUST COMPLETE THIS CERTIFICATION ONLY FORAFIRST-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:

_________________________________________________________________________ (_____)_____________________

(Name of Trainer)(Telephone Number)

_______________________________________________________________________________________________________

(Address of Trainer)

___________________________________________________________________

_________________________________

(Signature of Patient)

(Date Training Completed)

 

 

MV-80L(1/13)

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