State of Maine Eye Examination Form

State of Maine Eye Examination Form

State of Maine Eye Examination Form

State of Maine Eye Examination Form

Kennebec Eye Care​​​​​​​, P.A.

State of Maine

Bureau of Motor Vehicles
Eye Examination Form

This section is to be completed by Driver.

Name

Date of Birth

Address

Driver's License Number

Telephone Number

To be completed by a Licensed Vision Examiner
Based on your examination of this patient and according to Functional Ability Profile rules (FAP).

Visual Acuity

Right Eye

Without Correction

With Correction

Left Eye

Telescopic or bioptic lenses are not permitted for the visual acuity tests above.

Visual Fields
If visual field is less than 50° to left & 50° to right of fixation, or if less than 120° total, see FAP guidelines.

Left of point of fixation

Right of point of fixation

Total Degrees

Ocular Motility

Is there definite ocular motility that is likely to produce diplopia or other safety hazard?

Please provide FAP profile level & treatment required to correct diplopia

Other Eye Conditions (please indicate those that apply)

Reexamination recommeded in

License Restrictions
Corrective Lenses - Corrected visual acuity of 20/100 or better
Daylight-only driving - Best eye corrected visual acuity of 20/50 to 20/100.
Correctable diplopia may also require a license restriction.

Other Recommendations

Vision Examiner Name

Date of Exam

Address

Telephone

Signature

Date

IMPORTANT EYE EXAMINATION INFORMATION
Maine law requires that individuals have their eyes tested when applying for a license, at certain renewal times and/or when required because of certain eye conditions. The date of exam on this form must not be more than one year prior to receipt by BMV. 29-A MRSA §1258 and §1303

FOR DRIVER’S LICENSE EXAMINATION APPLICANTS
A vision test is required prior to taking your driver’s license examination. You may take a vision test at no fee when you appear for your driver’s examination. Alternatively, you may have a doctor of your choice provide the exam at your expense. The doctor who conducts the examination must complete the reverse side of this form. You will need to give the completed form to the driver’s license examiner at the time of your driver’s examination.

FOR INDIVIDUALS RENEWING A DRIVER’S LICENSE
A vision screening is required for individuals renewing their license at the first license renewal after attaining age 40 and at every 2nd renewal after that. A vision screening is required at every license renewal after attaining age 62. It is not required that you visit an eye doctor.

Vision testing can be completed at any branch office or mobile unit location at no cost to you. This exam will be completed at the time of renewal, and the results will be recorded on your renewal form.

Alternatively, you may have a doctor of your choice provide the eye exam at your own expense. The doctor who conducts the exam must complete the reverse side of this form. You will need to bring the completed form with you when you come in to renew your license. The doctor’s exam may not be completed more than a year prior to your license renewal date.

FOR INDIVIDUALS WITH CERTAIN EYE CONDITIONS
An Eye Examination Form may be required of individuals with certain vision conditions. When required to submit an eye examination form, you may have the doctor of your choice provide the exam at your own expense. The doctor who conducts the exam must complete the reverse side of this form.

Please mail or fax the completed form to:
Bureau of Motor Vehicles, Medical Section
29 State House Station, Augusta, ME 04333-0029
Fax: (207) 624-9319

Questions or concerns, call: (207) 624-9000, ext. 52124
Website: http://www.maine.gov/sos/bmv/licenses/medical.html

Authorization for Release of Medical Information

I hereby authorize the release of my medical history by

to the Bureau of Motor Vehicles. I understand that this information may be shared with any qualified health care professional submitting information pertaining to the disclosed medical history for the purpose of determining my eligibility for a driver's license.

Patient Signature

Phone Number

Date

chance0524 none 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM 9:00 AM - 5:00 PM 8:00 AM - 5:00 PM 8:00 AM - 5:00 PM Closed Closed optometrist https://www.google.com/maps/place/Kennebec+Eye+Care/@44.5537945,-69.6342705,17z/data=!3m1!4b1!4m5!3m4!1s0x4cb1e47e5bd98651:0x767e5e6208170243!8m2!3d44.5538151!4d-69.6319013 https://www.facebook.com/KennebecEyeCare/reviews/?ref=page_internal