New York > Statewide > Department Of Motor Vehicles
Physicians Statement MV-80 - New York
| Physicians Statement 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 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 Date of Birth CID Date of Examination Please print or type Patient's Name Have you treated this patient? 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? 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 o No 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 Specialty License Number Telephone Number ( ) ç Address State MV-80 (9/11) www.dmv.ny.gov American LegalNet, Inc. www.FormsWorkFlow.com
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