Di-4v Vision Specialist Statement Of Examination Form
Download a blank fillable Di-4v Vision Specialist Statement Of Examination Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Di-4v Vision Specialist Statement Of Examination Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4Clear Form
VISION SPECIALIST’S STATEMENT OF EXAMINATION
Michigan Department of State
INSTRUCTIONS FOR DRIVER/APPLICANT
The Department of State is seeking information to determine if you have a visual condition that may affect your ability to
drive safely. This request is based on results of a vision screening at a Secretary of State office or other information
received by the department. Please complete Sections 1 and 2 and then have your vision specialist complete the other
sections. Either you or your vision specialist may return the completed form to the department. Failure to have this form
completed and returned may result in the suspension of your driver’s license or the denial of your license application.
Information provided in this statement must be based on a vision examination completed within the last six months.
Payment for any examination and the preparation of this form is your responsibility. The decision to grant, suspend or
reinstate an individual’s driving privileges rests solely with the Department of State, which may consider other facts or
conditions when making this decision.
INSTRUCTIONS FOR VISION SPECIALIST
The Department of State is seeking assistance in determining the visual condition of this patient. Your professional
opinion, the answers to these questions, and any other pertinent information will help the department assess this
individual’s ability to safely operate a motor vehicle. After the patient has completed Sections 1 and 2, please complete
Sections 3 through 7. If you need additional information, please contact the department at (517) 335-7051. Either you or
your patient may return the completed form to the department.
SECTIONS 1 AND 2 TO BE COMPLETED BY DRIVER/APPLICANT
SECTION 1: GENERAL INFORMATION
(Please print or type)
Name (First, Middle, Last)
Date of Birth
Driver’s License Number
Street Address
Telephone Number 8 a.m. – 5 p.m.
City
State
ZIP
Today’s Date
I authorize the release of information to the Department of State only for the purpose of assisting in evaluating my
ability to safely operate a motor vehicle. I certify that my responses contained in this document are true and accurate to
the best of my knowledge and belief.
Driver/Applicant’s Signature: _____________________________________________________________________
Please complete the following information if you assisted the driver/applicant with the completion of this form.
Name _________________________________________________ Telephone Number ________________________
Address ________________________________________________________________________________________
I am completing Sections 1 and 2 of this form at the request of the driver/applicant.
Relationship to
Signature: _________________________________ Driver/Applicant: ______________________Date:___________
Please mail, fax, or e-mail to:
Michigan Department of State
P.O. Box 30810, Lansing, Michigan 48909-9832
Phone: (517) 335-7051; Fax: (517) 335-2189; E-mail: medicalforms@michigan.gov
DI-4V (2-13)
Page 1 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal