Form MV-80L - Eye Test Report for Medical Review Unit - New York
l 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 UNIT AT THE ADDRESS SHOWN IN THE BOX ABOVE.
l If this completed questionnaire and all related statements are not returned to the Medical Review Unit (at their
address above), your license may be suspended.
YOU MUST HAVE APPROVAL FROM THE MEDICAL REVIEW
UNIT BEFORE YOU CAN OBTAIN A VALID LICENSE. ALL MEMBERS OF THE LOW VISION PROGRAM ARE
REQUIRED TO PROVIDE AN EVALUATION STATEMENT FROM THEIR EYE CARE PROVIDER EVERY
6 MONTHS OR ONCE A YEAR, DEPENDING UPON THE RECOMMENDATION OF THE EYE CARE PROVIDER.
MINIMUM STANDARD FOR INDIVIDUALS WITH CORRECTED VISION OF LESS THAN 20/40, BUT NOT LESS
l Horizontal, binocular field of vision must be no less than 140 degrees.
MINIMUM STANDARD FOR TELESCOPIC LENS WEARERS:
l 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.
l Clip-on or hand-held telescopic lenses are not acceptable
l Visual acuity (Snellen Method) through telescopic portion in either or both eyes must be NO LESS THAN 20/40
l Visual acuity (Snellen Method) through carrier lens in either or both eyes must be NO LESS THAN 20/100
l Total horizontal, binocular field of vision (no field expanders) must be NO LESS THAN 140 DEGREES
l Must pass road test if he/she has not taken a road test while wearing his/her telescopic lenses
l Eligible for a Class D or DJ driver license only
l Ineligible for a commercial driver license (CDL), a motorcycle license or a moped license.
PATIENT — COMPLETE THIS SECTION
Please Print or Type
(Last) (First) (M.I.)
(Number and Street) (Apt. No.)
(City) (State) (Zip Code)
New York State Client ID # ______________________ Date of Birth __________________ o Male o Female
PAGE 1 OF 2
(QUESTIONNAIRE FOR PERSONS WITH CORRECTED VISION OF LESS THAN 20/40
BUT NOT LESS THAN 20/70, OR TELESCOPIC LENS WEARERS)
EYE TEST REPORT FOR MEDICAL REVIEW UNIT
Medical Review Unit, Rm. 337
New York State
Department of Motor Vehicles
6 Empire State Plaza
Albany NY 12228
STATE OF NEW YORK
DEPARTMENT OF MOTOR VEHICLES
6 EMPIRE STATE PLAZA, ALBANY NY 12228
Form MV-80L - Eye Test Report for Medical Review Unit - New York PDF
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