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Eye Test Report Form. This is a New York form and can be use in Department Of Motor Vehicles Statewide.
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Tags: Eye Test Report, MV-619, New York Statewide, Department Of Motor Vehicles
New York State Department of Motor Vehicles
MV-619 (10/11)
EYE TEST REPORT
TO THE HEALTH CARE PROFESSIONAL:
This form should be used only for patients who are able to achieve a minimum Snellen Test score of 20/40 with one or both eyes, with
or without the use of corrective lenses. Please refer to the “NOTE” at the bottom of this page.
TO THE DRIVER LICENSE CUSTOMER:
After your health care professional completes this report, take the report to any Motor Vehicles office when applying for a driver
license or when renewing a driver license. To avoid a trip to DMV, mail this completed report with your license renewal application
(MV-2) or use it when renewing your license at the DMV web page at: www.dmv.ny.gov/licrenew.
INSTRUCTIONS
1. In most situations, this report is valid for 12 months from the date of examination. However, based on the results of the test and
on the health care professional’s assessment of the patient’s visual health, the person who administers the test can specify that
this report be valid only for 6 months from the date of the examination. The appropriate box in number 11 must be checked.
2. Eye test examinations may be conducted only by a licensed physician, ophthalmologist, optometrist, nurse practitioner,
physician’s assistant, optician or registered nurse.
3. PRINT in ink or TYPE all information below (except for signatures).
4. Be sure to enter the patient’s name exactly as it appears on the driver license.
5. Have the patient sign his/her full name in box number 8.
6. Sign your name in full, and provide your professional license number, in box number 12.
7. Give this report to the patient. Do not mail this report.
1. Patient’s Last Name
First
2. Date of Birth (Mo./Day/Yr.)
M.I.
/
3. Sex
oM oF
/
4. Patient’s Address
(Number and Street)
Apt. #
City
State
5. Best Vision Test Score (Snellen) with or without corrective lenses.
Right
Left
Zip Code
6. Date of Examination
(Mo./Day/Yr.)
Both
/
/
7. Did the patient wear corrective lenses to achieve a Snellen Test score of 20/40 with one or both eyes?
o YES
o NO
8. Patient’s Signature (Sign Name in Full)
Sign Here
-__________________________________________________________________________________________________________________________
I have examined the patient described above, and have accurately reported my findings from that examination on this form.
9. Name and Title
of Examiner
10. Examiner’s Address
(Number and Street)
City
State
11. This report is valid for up to (check one)
o 12 months o 6 months
from the date of examination.
Professional
12. Examiner’s Signature (Sign Name in Full)
Sign Here
Zip Code
-________________________________________________________________________________
License.
No. ____________________________________
NOTE: For patients whose best corrected vision is less than 20/40 but not less than 20/70, and for patients who
wear telescopic lenses, complete form MV-80L and mail it to the address on that form. The MV-80L can be
downloaded from the DMV website at www.dmv.ny.gov/forms/mv80L.pdf or by calling:
u
Metropolitan New York City
- From the 212, 347, 646, 718, 917 or 929 area codes:
(212) 645-5550 or (718) 966-6155
u
From the 516, 631, 845, 914 area codes:(718) 477-4820
u
From Upstate New York (all other area codes)
(518) 486-9786
u
From out of New York State: (518) 473-5595
u
TDD: 1-800-368-1186 from anywhere in New York
www.dmv.ny.gov
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