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 |