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Physicians Statement Form. This is a New York form and can be use in Department Of Motor Vehicles Statewide.
Tags: Physicians Statement, MV-80, New York Statewide, Department Of Motor Vehicles
New York State Department of Motor Vehicles
PHYSICIAN’S STATEMENT
To Our Driver License Customer:
Motor Vehicles has been notified that you have had, or are currently receiving treatment for, a medical condition that may impair
your ability to safely operate a motor vehicle.
More information from your doctor about this condition is required. Please have your doctor fill out the statement below.
IMPORTANT: The information provided in the statement must be based on an examination of you that this doctor performed
within the last six months.
After the doctor completes the statement, please bring the statement and a sample of the doctor’s stationery (or a voided
prescription blank from the doctor’s office) to any Motor Vehicles office.
o For re-examination, please bring this form on the date of your scheduled appointment.
Please be assured that all medical information we receive from you and your doctor will be treated as strictly personal and confidential.
Thank you for your help.
Department of Motor Vehicles
Please print or type
Patient’s Name
Date of Birth
Have you treated this patient?
CID
Date of Examination
o Yes o No
If “Yes”, please describe the condition you treated or are treating: ____________________________________________
____________________________________________________________________________________________
Is the patient receiving medication for this condition?
o Yes o No
If “Yes”, please specify the type and dosage: ____________________________________________________________
____________________________________________________________________________________________
Has the patient suffered any loss of body control, awareness or consciousness due to this condition?
o Yes o No
If “Yes”, please complete DMV form MV-80U.1, Physician’s Statement for Medical Review Unit.
In your opinion, would this patient’s condition, or the medication he/she is taking, interfere with his/her ability to safely operate a
motor vehicle?
o Yes - permanently
o Yes - temporarily
o No
If “No”, do you recommend the Department conduct an on-the-road driving performance evaluation?
o Yes, please explain __________________________________________________________________________________
o
_________________________________________________________________________________________________
No
DOCTOR – please give your patient a sample of your stationery (showing your letterhead), or a voided prescription blank, as
additional verification for this statement.
Physician’s Signature
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Telephone Number
(
Specialty
Address
License Number
State
)
MV-80 (9/11)
www.dmv.ny.gov
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