Form VI-4 at a glance
What it is: This is the Texas Department of Public Safety Regulatory Services Division application for window tint medical exemption.
Where and when to file: Fax to (512) 424-2774. Please allow up to 15 working days for your application to be processed, approved and to receive your exemption.
What to bring and attach to Form VI-4
The completed application must be accompanied by one of the following: a letter, on physician letterhead, signed by the physician, indicating the medical reason for the exemption.
Or an original prescription including the applicant's name, physician's signature and indicating the medical reason for the exemption.
Letters and prescriptions must be dated within one year of exemption request. If the exemption is approved, an exemption letter will be sent to the applicant.
A filled-in Form VI-4 example: a patient applies for herself
How to fill out Form VI-4, box by box
Applicant and patient
Enter the applicant's Name as it appears on the driver license, with the DL #, State and Expiration.
Enter the Patient Name and the Relationship to Applicant if the patient is different from the applicant.
Enter the Residence Address with City, State, County and ZIP, and the Mailing Address with City, State, County and ZIP.
Enter the Date of Birth, Home Phone, Cell Phone, Email, Business Phone and Other Phone.
Vehicle information
Under VEHICLE INFORMATION, enter the VIN, Year, Make and Model for Vehicle #1, Vehicle #2 and Vehicle #3.
Physician, optometrist or ophthalmologist
Under PHYSICIAN, OPTOMETRIST OR OPHTHALMOLOGIST, enter the Name, License #, Address, City, State, Zip, Email, Phone and Fax.
Sign
Sign on the Applicant / Legal Guardian's Signature line and enter the Date to certify that all information presented in this form is true and correct, that any documents presented to DPS are genuine, and that the information included in all supporting documentation is true and accurate.
Knowingly making a false statement or representation on this form is a criminal violation.
More rules for Form VI-4
You must use the most current form. The form must be typed.
Please allow up to 15 working days for your application to be processed, approved and to receive your exemption.
Common questions about Form VI-4
Where do I file it?
SUBMIT the completed form with required documentation by Online Secured Email: select “Vehicle Inspection” and complete the online form. Fax to (512) 424-2774. Mail to Texas Department of Public Safety Regulatory Services Division, Compliance & Enforcement Service Window Tint Medical Exemption P. O. Box 4087 Austin, Texas 78773-0543.
Sources
[1] Form VI-4 (Rev. 3/16), Application for Window Tint Medical Exemption, Texas Department of Public Safety (the Official source link on this page).