Fillable Form 32-4001 - Vision Examination Report (Page 2 of 2) in pdf

Form 32-4001 - Vision Examination Report Page 2

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Driver Instructions

Under the statutory authority below, you are required to have this Vision Examination Report completed by a

physician or optometrist. The physician or optometrist must mail the completed report to the Motor Vehicle

Division at the address on the form. It must be received within 30 days from the Date of Notice. Failure to do so

will result in suspension or revocation of your driving privilege. Should this form be received incomplete, it will

be returned to you. This will result in a delay in your evaluation. The physician or optometrist must be licensed to

practice medicine, osteopathy, homeopathy, optometry or psychiatry in this state, or another state, or employed by

the federal government to practice in this state.

You must complete and sign the “Medical Information Release” on this form before giving it to your physician.

The completed form will be evaluated by the Medical Review Program. Based upon the information provided,

MVD will make a licensing decision. It is possible that you may be required to submit additional medical

information and successfully complete any required testing.

Any driver experiencing any medical condition that affects driving ability is required to report the condition to

MVD as soon as the medical condition allows.

Physician/Optometrist Instructions

The driver must have this form completed to be eligible for a driver license. Your response to the questions on

this form will indicate to MVD how this person’s medical condition affects his or her ability to safely perform the

functional skills involved in driving. You must mail the completed report to the Motor Vehicle Division at the

address on this form. It must be received within 30 days from the Date of Notice.

Arizona law provides immunity from personal liability to physicians in supplying completed medical forms. It is

important that your patient signs the release statement on the top of the form. This gives you the authorization to

release pertinent medical information to MVD. State law makes MVD responsible for the licensing decision on

individuals.

All sections of the form must be completed. If any of the questions are not applicable to your patient, indicate this

in the response section. Incomplete forms will not be accepted and will be returned, which will delay the

evaluation.

Authority

Arizona Revised Statutes (ARS) 28-3005, 28-3314; Arizona Administrative Code R17-4-502, R17-4-503

Form 32-4001 - Vision Examination Report Page 2

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