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Complete the customer information section before the eye exam and have the provider complete the vision examination within 90 days prior to DMV submission. Submit the completed report to the listed address, and note that any charges for form completion are the customer’s responsibility. Include required identity details, exam dates, visual acuity, visual field measurements, and provider certification.",{"@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-vision-examination-request-complete-prior-to-dmv-submission/445867/",{"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-vision-examination-request-complete-prior-to-dmv-submission/445867.png","ImageObject",300,407,{"name":92,"@type":93},"Fahsai","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",15,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"When must the vision examination be conducted before submitting the report to DMV?","Question",{"text":113,"@type":114},"The vision examination must be conducted within 90 days prior to submitting the report to DMV.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What must the ophthalmologist or optometrist complete in the vision examination section?",{"text":118,"@type":114},"They must provide first and most recent exam dates, document vision standards, record visual measurements (visual acuity and visual fields), list any ocular conditions affecting safe vehicle operation, and include required visual field analysis information when applicable.",{"name":120,"@type":111,"acceptedAnswer":121},"Are costs for completing the form the patient’s responsibility?",{"text":122,"@type":114},"Yes. Any charges related to or incurred as part of completing the form are the customer’s responsibility.","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},445867,1790915721,{"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":144,"read_time":24,"preview_page_count":4},549768702563,"https://ap-avatar.wpscdn.com/avatar/8000c4aa63b76e948b?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786536092046926083","# CUSTOMER VISION REPORT\n\nUse this form to request vision examination information from your ophthalmologist or optometrist.  \n## Purpose:\n\nInstructions:Complete the Customer Information section and have your Ophthalmologist/Optometristcomplete the Vision Examination section.The vision examination must be conducted within 90days prior to submission of the report to DMV.Mail the completed report to the address above.Note:Any charges related to or incurred as part of the completion of this form are yourresponsibility.  \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 identfication (D)card may be canelled.   |  |  |  |  |  |  |\n| NAME(last)   | (first)   | (mi)   | (suffix)   | CUSTOMER NUMBER(from your driver license)or SSN   |  |  |\n| RESIDENCE/HOME ADDRESS   |  |  | Check if this is a new address,your  \u003Cbr>address will be changed on DMV's system.   |  |  | BIRTHDATE(mm/ddlyyy)   |\n| CITY   |  |  | STATE  \u003Cbr>V   | ZIP CODE   | CITY OR COUNTY OF RESIDENCE   |  |\n| MAILINGADDRESS (if different from above)   |  |  |  |  |  |  |\n| CITY   |  |  | STATE   | ZIP CODE   | DAYTIME TELEPHONE NUMBER   |  |\n\n\n| VISION EXAMINATION (to be completed by Ophthalmologist/Optometrist)   |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| FIRST EXAMINATION DATE(mm/dd/yyyy)   |  |  | MOST RECENTEXAMINATION DATE(mm/ddlyyy)   |  |  |  |  |  | VISION STANDARDS   |\n|  |  |  |  |  |  |  |  |  | DRIVER'S LICENSE:  \u003Cbr>▶20/40 or better vision in one or both eyes,and  \u003Cbr>▶ 110 degrees,or better,horizontal vision in one  \u003Cbr>or both eyes.  \u003Cbr>RESTRICTED TO DAYLIGHT HOURS ONLY:  \u003Cbr>▶20/70 or better vision in one or both eyes,and  \u003Cbr>▶70 degrees,or better,horizontal vision.  \u003Cbr>If vision is limited to only one eye,40 degrees or  \u003Cbr>better temporal and 30 degrees or better nasal  \u003Cbr>are required.  \u003Cbr>COMMERCIAL DRIVER'S LICENSE:  \u003Cbr>(See Note \"B\"on page 2)  \u003Cbr>▶20/40 or better vision in each eye  \u003Cbr>▶ 140 degrees or better horizontal vision   |\n| VISUAL MEASUREMENTS (See Note \"A\"on page 2)   |  |  |  |  |  |  |  |  |  |\n| Uncorrected Visual Acuity   | RIGHTEYE(OD)   | LEFTEYE(OS)   |  |  | BOTH EYES(OU)   |  |  |  |  |\n| Best Corrected Visual Acuity   | RIGHTEYE(OD)   | LEFTEYE(OS)   |  |  | BOTH EYES (OU)   |  |  |  |  |\n| Horizontal Visual Field (fields must be in degrees)METHOD:  \u003Cbr>□Vision in both eyes  \u003Cbr>□ Vision limited to one eye only  \u003Cbr>□RIGHTEYE (OD)□LEFT EYE (OS)  \u003Cbr>DMV Visual Field information:See Note C on page 2.   |  |  |  | TEMPORAL-OD  \u003Cbr>TEMPORAL-OS   |  | NASAL-OD  \u003Cbr>NASAL-OS   |  |  |  |\n| Does the patient have any ocular condition(s)that would affect the safe operation of a motor vehicl  \u003Cbr>□YES □NO  \u003Cbr>If YES,indicate condition below.  \u003Cbr>Does the patient have any condition that would affect the peripheral visual field?  \u003Cbr>YES □NO  \u003Cbr>IfYES,please provide a graphic visual field analysis out to 120 deg  \u003Cbr>other threshold perimetry test (see Note C on page 2).   |  |  |  |  |  |  |  | e?  \u003Cbr>rees in each eye.Preferably a HVF 30-2 AND 60-4 or   |  |\n| PLEASE LISTALL OCULAR CONDITIONS   |  |  |  |  |  |  |  |  |  |\n\n\n| TRIST CERTIFICATION  \u003Cbr>OPHTHALMOLOGIST/OPTOMET   |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n| MEDICAL PROVIDER NAME(print)   |  | CHECK BOX THAT APPLIES:  \u003Cbr>OPHTHALMOLOGIST  \u003Cbr>□OPTOMETRIST   |  |  |  |  |\n| MEDICAL LICENSE NUMBER   | EXPIRATION DATE(mm/ddlyyy)   |  |  |  | STATE ISSUING LICENSE TO PRACTICE   |  |\n| BUSINESS ADDRESS   |  |  |  |  |  | TELEPHONE NUMBER  \u003Cbr>(      )   |\n| CITY   |  |  | STATE   | ZIP CODE   |  | FAX NUMBER  \u003Cbr>(      )   |\n| MEDICAL PROVIDER SIGNATURE   |  |  |  |  |  | DATE(mm/dd/yyyy)   |\n\nDMV USE ONLYCSC STAFF-do NOTsend MED 4 back withdaly work unless there isan ocular condition orc","cbCairfiW39YMc5D","https://ap.wps.com/l/cbCairfiW39YMc5D","pdf",622821,"English","# Purpose\n## Customer Information\n## Vision Examination\n## Tri st Certification\n## Notes\n## High Risk Ophthalmic Conditions Requiring a Visual Field Analysis","[{\"question\":\"When must the vision examination be conducted before submitting the report to DMV?\",\"answer\":\"The vision examination must be conducted within 90 days prior to submitting the report to DMV.\"},{\"question\":\"What must the ophthalmologist or optometrist complete in the vision examination section?\",\"answer\":\"They must provide first and most recent exam dates, document vision standards, record visual measurements (visual acuity and visual fields), list any ocular conditions affecting safe vehicle operation, and include required visual field analysis information when applicable.\"},{\"question\":\"Are costs for completing the form the patient’s responsibility?\",\"answer\":\"Yes. Any charges related to or incurred as part of completing the form are the customer’s responsibility.\"}]","CUSTOMER VISION REPORT - Vision Examination Request - Complete Prior to DMV Submission | PDF",1790713077]