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Physicians Statement For Medical Review Unit MV-80U.1 - New York
| Physicians Statement For Medical Review Unit Form. This is a New York form and can be used in Department Of Motor Vehicles Statewide . |
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New York State Department of Motor Vehicles PHYSICIAN'S STATEMENT FOR MEDICAL REVIEW UNIT To Our Driver License Customer: Use this form to report medical, physical, mental or a combination of such conditions to the Medical Review Unit. Please complete the information below and have your doctor complete the statement on Page 2. IMPORTANT: The information provided must be based on a current examination performed by your physician within the last 120 days from the date this statement is submitted. Information provided by an emergency care doctor, nurse practitioner or physician's assistant is NOT acceptable. After review of the completed statement you may be requested to provide additional information from either the physician who provided the information or from a qualified specialist. PLEASE PRINT OR TYPE Last Name First Name M.I. Date of Birth (Month/Day/Year) Male Female / Mailing Address (Number and Street) City State / Zip Code Client ID No. (Driver License No.) Any other names that you have used (if applicable) Daytime Telephone Number (Area Code) ( ) I am being treated and/or have been treated for the following medical, physical, or mental condition(s): ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Please check the appropriate box(es) below and fill in your doctor's name: I am being treated primarily by my primary care physician, Dr. _____________________________________________. I am being treated by my specialist, Dr. _______________________________________________. I am being treated by my psychiatrist/psychologist, Dr. ___________________________________________. Please have your physician complete page 2, and then return this form to: Department of Motor Vehicles Driver Improvement Bureau Medical Review Unit 6 Empire State Plaza, Room 220 Albany, NY 12228 (518) 474-0774 MV-80U.1 (7/08) Visit us at: www.nysdmv.com PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com THIS SIDE IS TO BE COMPLETED BY YOUR PHYSICIAN Physician: Please attach a sample of your letterhead or a voided prescription blank. PLEASE PRINT OR TYPE Patient's Last Name First Name M.I. Date of Birth (Month/Day/Year) Male Female / / / / 1. Examination Date (must be within 120 days from the date this form is submitted): _______________________ 2. Condition patient is being treated for: Epilepsy/convulsive disorder Syncope/fainting/dizziness or Diabetes Sleep disorder Dementia/senility/Alzheimer's a condition that causes unconsciousness Head trauma/tumor Heart condition Stroke Neurological or neuromuscular disease Mental disorder Other (please specify) ____________________________________________________________________________________ 3. Symptoms, severity, and frequency of condition:____________________________________________________________________ __________________________________________________________________________________________________________ 4. Date of the last episode/incident associated with this condition: ________________________________________________________ 5. Have any episode(s)/incident(s) associated with this condition caused any loss of consciousness, awareness, and/or body control? YES NO If YES, list the dates of the episode(s)/incident(s) ____________________________________________________ __________________________________________________________________________________________________________ 6. Give a brief description regarding any factors that may have caused/contributed to the episode(s)/incident(s): __________________ __________________________________________________________________________________________________________ 7. To the best of your knowledge have any of the patient's episode(s)/incident(s) resulted in a motor vehicle accident(s) and/or incident(s)? YES NO If YES, please give details and the dates of the episode(s)/incident(s) and related accident(s): __________________ __________________________________________________________________________________________________________ 8. Tests conducted (e.g., EEG, EKG, MRI, sleep study, serum levels, etc.): ________________________________________________ 9. Current treatment, medication and dosage, and /or therapy: ____________________________________________________________ __________________________________________________________________________________________________________ The following MUST be answered if the patient has a sleep disorder: a.) Date first diagnosed with the sleep disorder:___________________________ b.) Is patient receiving treatment? _______ Type of treatment _______________________ Date treatment began:____________ c.) Is patient compliant with the treatment?_______________________________________________ 10. In your medical opinion, at this time, would the patient's condition interfere with the safe operation of a motor vehicle? YES NO (If YES, please explain in the space provided or in an attached statement on your letterhead.) __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ NOTE: If you answered YES to question 10, skip Question 11. 11. Do you recommend the Department conduct an on-the-road driving performance evaluation? YES NO If YES, please explain: ______________________________________________________________________________________ ________________________________________________________________________________________________________ Physician's Name (Please print in full) Certificate or license number and state where licensed Physician's Mailing Address (include number and street) Telephone Number (area code) ( ) Neurologist Psychiatrist/Psychologist City State Zip Code Primary care physician Endocrinologist Other _________________________________ Date (Month/Day/Year) Physician's Signature (Information p
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