[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-295090-105":59,"doc-detail-295090-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","customer-vision-report-complete-the-med-4-form-for-dmv-vision-review","CUSTOMER VISION REPORT - Complete the MED 4 form for DMV vision review","","CUSTOMER VISION REPORT form for requesting DMV vision documentation, including driver’s license renewal, medical review, and CDL waiver processing. Customers complete personal information before an eye examination, where an ophthalmologist or optometrist records examination dates, visual/ocular conditions, and whether any peripheral visual field limitations may affect safe driving. The form includes visual measurements such as visual acuity and horizontal visual field results, plus provider certification and notes referencing Virginia/DMV standards and required reporting timelines.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/customer-vision-report-complete-the-med-4-form-for-dmv-vision-review/295090/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/customer-vision-report-complete-the-med-4-form-for-dmv-vision-review/295090.png","ImageObject",300,407,{"name":92,"@type":93},"Jordan Avery","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-18",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",26,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"Who should fill out the CUSTOMER INFORMATION section, and when?","Question",{"text":113,"@type":114},"The customer completes the CUSTOMER INFORMATION section prior to the vision examination.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"How is the MED 4 form submitted for a medical review?",{"text":118,"@type":114},"The completed form is faxed by the doctor to Medical Review Services at 804-367-1604.",{"name":120,"@type":111,"acceptedAnswer":121},"What happens if the patient has visual/ocular conditions that could affect driving?",{"text":122,"@type":114},"The provider indicates conditions that could affect driving and, when applicable, supplies a graphic visual field analysis to specified degrees as required by the form’s guidance.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},295090,1789713590,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":130,"read_time":24},1099523882367,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","CUSTOMER VISION REPORT  \nInstructions:If you would like to have your vision tested by your doctor,have failed the vision test at DMV,are on vision review,or areseeking a CDL waiver,please fill out the Customer Information section of this form and take it with you to yourophthalmologist or optometrist to complete.Any charges incurred for the completion of this form are your responsibility.  \nDo you need a vision report for(check one):  \n□An upcoming driver's license renewal?Bring the completed form to any DMV customer service center within 90 days.  \n□A medical review?Have your doctor fax the completed form to Medical Review Services at 804-367-1604.  \n□A CDL waiver?Have your doctor fax this completed form and the MED 30 form to Medical Review Services at804-367-1604.  \nCSC STAFF  [Do NOT send MED 4 back with daily work unless the applicant has a condition that affects the eye or vision OR customer        cannot be licensed due to a MED 6 calculation.                                         \n\n| CUSTOMER INFORMATION (To be completed by customer PRIOR to vision examination)   |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| If you change either your residence/home address or maling adressto a non-Vigina address,your driver icense or phot idetfcation (D)card may be canelled.   |  |  |  |  |  |\n| NAME(last)   | (first)   | (mi)   | (suffix)   | CUSTOMER NUMBER(from your driver license)or SSN   |  |\n| RESIDENCE/HOME ADDRESS   |  |  |  |  | BIRTHDATE(mm/ddyyyy)   |\n| CITY   |  |  | STATE   | ZIP CODE   | CITY OR COUNTY OF RESIDENCE   |\n| MAILING ADDRESS(if different from above)   |  |  |  |  |  |\n| CITY   |  |  | STATE   | ZIP CODE   | DAYTIME TELEPHONE NUMBER  \u003Cbr>(__    )   |\n\n\n| VISION EXAMINATION (to be completed by Ophthalmologist/Optometrist)   |  |\n| --- | --- |\n| FIRST EXAMINATION DATE   | MOST RECENT EXAMINATION DATE   |\n| Does the patient have any visual/ocular condition(s)that could affect the ability to drive a motor vehicle?  \u003Cbr>f YES,indicate condition below.  \u003Cbr>□NO  \u003Cbr>□YES  \u003Cbr>Does the patient have any condition that would affect the peripheral visual field?  \u003Cbr>□NO  \u003Cbr>YES  \u003Cbr>IfYES,please provide a graphic visual field analysis to 120 degrees total in each eye.Preferably a HVF 30-2 AND 60-4 or  \u003Cbr>other threshold perimetry test (see Note Con page 2 for the list of conditions requiring a Visual Field).   |  |\n| PLEASE LIST ALL VISUAL/OCULAR CONDITION(S)   |  |\n| PROVIDER COMMENTS   |  |\n\n\n| VISUAL MEASUREMENTS   |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Check applicable:  \u003Cbr>□Vision Limited to RIGHT EYE (OD)ONLY □Vision Limited to LEFTEYE(OS)ONLY  \u003Cbr>□Vision in both eyes   |  |  |  |  |  |  |  |  |  |  |\n| VISUAL ACUITY (See Note \"A\"on page 2)   |  |  |  | HORIZONTALVISUAL FIELD(fields must be in degrees)   |  |  |  |  |  |  |\n| Uncorrected Visual  \u003Cbr>Acuity   | RIGHT EYE(OD)   | LEFT EYE (OS)   | BOTH EYES (O  \u003Cbr>20/   | U)|DMVVisual Field information:See Note C on page 2.  \u003Cbr>METHOD:(check one)  \u003Cbr>□AUTOMATED  \u003Cbr>□CONFRONTATION  \u003Cbr>NASAL-OD  \u003Cbr>TEMPORAL-OD  \u003Cbr>TEMPORAL-OS NASAL-OS   |  |  |  |  |  |  |\n| Best Corrected Visual  \u003Cbr>Acuity   | RIGHT EYE(OD)  \u003Cbr>20/   | LEFT EYE (OS)   | BOTH EYES(OU)  \u003Cbr>20/   |  | 0-100(degrees)   | 0-60(degrees)   |  | 0-100(degrees)   | 0-60(degrees)   |  |\n\n\n| OPHTHALMOLOGIST/OPTOMETRIST CERTIFICATION   |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| MEDICAL PROVIDER NAME(print)   |  | CHECK BOX THAT APPLIES:  \u003Cbr>□OPHTHALMOLOGIST  \u003Cbr>□OPTOMETRIST   |  |  |  |  |\n| MEDICAL LICENSE NUMBER   | EXPIRATION DATE(mmddlyyy)   |  |  |  | STATE ISSUING LICENSE TOPRACTICE   |  |\n| BUSINESS ADDRESS   |  |  |  |  |  | TELEPHONE NUMBER  \u003Cbr>(      )   |\n| CITY   |  |  | STATE  \u003Cbr>√   | ZIP CODE   |  | FAX NUMBER  \u003Cbr>(    __)   |\n| MEDICAL PROVIDER SIGNATURE   |  |  |  |  |  | DATE(mm/dd/yyyy)   |\n\nAcceptable standards of vision for safe driving are determined by the Code of Virginia a","cbCaib1D6frt19Dt","https://ap.wps.com/l/cbCaib1D6frt19Dt","pdf",1153025,"English","# Customer Information\n## Vision Examination\n## Visual Measurements\n## Ophthalmologist/Optometrist Certification\n# High Risk Ophthalmic Conditions Requiring a Visual Field Analysis","[{\"question\":\"Who should fill out the CUSTOMER INFORMATION section, and when?\",\"answer\":\"The customer completes the CUSTOMER INFORMATION section prior to the vision examination.\"},{\"question\":\"How is the MED 4 form submitted for a medical review?\",\"answer\":\"The completed form is faxed by the doctor to Medical Review Services at 804-367-1604.\"},{\"question\":\"What happens if the patient has visual/ocular conditions that could affect driving?\",\"answer\":\"The provider indicates conditions that could affect driving and, when applicable, supplies a graphic visual field analysis to specified degrees as required by the form’s guidance.\"}]","CUSTOMER VISION REPORT - Complete the MED 4 form for DMV vision review | PDF"]