Form Mv-80li.1 - Physicians Statement For Medical Review Unit printable pdf download

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 physician/physician assistant/nurse practitioner complete the statement on Page 2.

IMPORTANT: The information provided must be based on a current examination performed by your physician/physician

assistant/nurse practitioner within the last 120 days from the date this statement is submitted.

NOTE: Information provided by emergency care personnel is NOT acceptable. After review of the completed statement

you may be requested to provide additional information from either the physician/physician assistant/nurse practitioner

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 physician/physician assistant/nurse practitioner’s name:

I am being treated primarily by my primary care physician, Dr. _____________________________________________.

I am being treated primarily by my nurse practitioner, N.P. _______________________________________________.

I am being treated primarily by my physician assistant, P.A. _____________________________________________.

I am being treated by my specialist, Dr. _______________________________________________.

I am being treated by my psychiatrist/psychologist, Dr. ___________________________________________.

Please have your physician/physician assistant/nurse practitioner complete page 2, and then return this form to:

Medical Review Unit

Driver Improvement Bureau

NYS Department of Motor Vehicles

6 Empire State Plaza

Albany, NY 12228

(518) 474-0774

PAGE 1 OF 2

Visit us at: dmv.ny.gov

MV-80U.1 (5/15)

Form Mv-80li.1 - Physicians Statement For Medical Review Unit