VISION TEST REPORT
dmv.ny.gov
PATIENT INSTRUCTIONS:
a. Find a provider in DMV’s Vision Registry at dmv.ny.gov/vision-registry-locator. If one of these providers completes
your required vision test, you do not need this form to renew your driver license.
b. If your provider is not enrolled in DMV’s Vision Registry, this report must be completed and used when renewing your license
at dmv.ny.gov or by mail.
PROVIDER INSTRUCTIONS:
a. This form should be used only for patients who have a minimum Snellen Test score of 20/40 with one or both
eyes, with or without corrective lenses. For patients whose best corrected vision is less than 20/40 but not less than
20/70, and for patients who wear telescopic lenses, complete form MV-80L (dmv.ny.gov/forms) and mail it to the address
on that form.
b. ONLYa licensed physician, physician assistant, registered nurse, nurse practitioner, optician, optometrist,
ophthalmologist, or supervised staff of any of these providers can complete the MV-619.
c. PRINT in ink or TYPE all information below except signature.
d. Do not mail this report. Give it to the patient.
e. To enroll in DMV’s Vision Registry, please visit dmv.ny.gov/visionprovide.htm. It’s simple, easy and free!
1. Patient’s Name (exactly as it appears on the patient’s driver license)
Last First MI
2. Date of Birth (MM/DD/YY)
/ /
3. Sex
M F
4. Patient’s Street Address
Apt. #
City State Zip Code
5. Date of Examination (MM/DD/YY)
/ /
6. Did the patient achieve a Snellen Test score of 20/40 or better with one or both eyes? If NO, complete form MV-80L
YES NO
7. Did the patient wear corrective lenses during the test?
YES NO
8. Name and Title of Provider
9. Provider’s Street Address
City State Zip Code
10. This report is valid for up to 12 months 6 months from the date of examination.
Provider’s Signature (Sign Name in Full)
Sign Here
X
11. I have examined the patient described above, and have accurately reported my findings from that examination on this form.
12. Professional License No.
MV-619 (6/15)
