"Bioptic Telescopic Lens Vision Examination" - Louisiana

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Bioptic Telescopic Lens Vision Examination is a legal document that was released by the Louisiana Department of Public Safety - a government authority operating within Louisiana.

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  • Released on December 1, 2008;
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LOUISIANA DEPARTMENT OF PUBLIC SAFETY
Office of Motor Vehicles
Bioptic Telescopic Lens Vision Examination
Authority for this requirement is based on laws of the State of Louisiana, relating to the issuance of the driver’s licenses.
INSTRUCTIONS TO APPLICANT
•
This form must be completed by the Optometrist or Ophthalmologist prescribing the bioptic telescopic lens.
•
This form must be completed based on an examination performed within 60 days.
•
Failure to complete and return the form to the Office of Motor Vehicles within 90 days may result in the suspension or
denial of driving privileges.
•
After this form is reviewed by the Office of Motor Vehicles, a final decision will be determined as to the eligibility of
issuance of driver’s license.
•
The applicant only qualifies for a class E license. Applicant is not eligible for a commercial driver license (CDL) or a
motorcycle endorsement.
•
The following statement must be read and signed: I hereby authorize the examining physician whose signature appears
below to release all information and findings contained herein to the Louisiana Department of Public Safety and Corrections.
The Louisiana Department of Public Safety and Corrections can release this information to such individuals or groups as may
be considered necessary and appropriate to determine my ability to safely operate a motor vehicle.
Signature of Patient: _______________________________
Date: __________________________
THIS SECTION IS TO BE COMPLETED BY THE OFFICE OF MOTOR VEHICLES
APPLICANT’S NAME ________________________DOB___________R/S________ DL#_______________
ADDRESS _____________________________________________________CITY______________________
DATE ISSUED_________________MVCA’S INITIALS___________BADGE #________OFFICE#________
EXAMINATION RESULTS FROM THE SNELLEN WALL CHART
WITH CARRIER LENSES:
WITH BIOPTIC TELESCOPIC LENS:
Right Eye
20/ ____________
Right Eye
20/ ______________
Left Eye
20/ ____________
Left Eye
20/ ______________
Both Eyes
20/ ____________
Both Eyes
20/ ______________
□
APPLICANT FAILED TO COMPLY WITHIN 90 DAYS
THIS SECTION IS TO BE COMPLETED BY OPTOMETRIST OR OPHTHALMOLOGIST
INSTRUCTIONS
•
The applicant must demonstrate a visual acuity of at least 20/200 in one or both eyes and a field of 110 degrees horizontal
vision without or with corrective carrier lenses. If he has vision in only one eye, he must have a field of at least 40 degrees
temporal and 30 degrees nasal horizontal vision.
•
The applicant must demonstrate a visual acuity of at least 20/60 in one or both eyes with the bioptic telescopic lenses and
without the use of field expanders.
•
The Optometrist or Ophthalmologist must certify that no ocular diagnosis or prognosis currently exists or is likely to occur
during the period of issuance of the license which would cause deterioration of visual acuity or visual field to levels below
the minimum standards.
•
This form must be completed in its entirety by an optometrist or ophthalmologist based on an examination performed within
60 days.
•
Incomplete forms may be rejected and could result in the denial of applicants driving privileges.
•
Clip on or hand-held telescopic lens are not acceptable.
PATIENT’S NAME ___________________________________________________ DOB ________________
□ Initial Evaluation □ Re-evaluation
EXAMINATION DATE _______________ (must be within 60 days)
WITH CARRIER LENSES:
WITH BIOPTIC TELESCOPIC LENS:
Right Eye
20/ ____________
Right Eye
20/ ______________
Left Eye
20/ ____________
Left Eye
20/ ______________
Both Eyes
20/ ____________
Both Eyes
20/ ______________
PERIPHERAL VISION FIELDS:
Left ____________________________________ Right ________________________________
Temporal
Nasal
Temporal
Nasal
LOUISIANA DEPARTMENT OF PUBLIC SAFETY
Office of Motor Vehicles
Bioptic Telescopic Lens Vision Examination
Authority for this requirement is based on laws of the State of Louisiana, relating to the issuance of the driver’s licenses.
INSTRUCTIONS TO APPLICANT
•
This form must be completed by the Optometrist or Ophthalmologist prescribing the bioptic telescopic lens.
•
This form must be completed based on an examination performed within 60 days.
•
Failure to complete and return the form to the Office of Motor Vehicles within 90 days may result in the suspension or
denial of driving privileges.
•
After this form is reviewed by the Office of Motor Vehicles, a final decision will be determined as to the eligibility of
issuance of driver’s license.
•
The applicant only qualifies for a class E license. Applicant is not eligible for a commercial driver license (CDL) or a
motorcycle endorsement.
•
The following statement must be read and signed: I hereby authorize the examining physician whose signature appears
below to release all information and findings contained herein to the Louisiana Department of Public Safety and Corrections.
The Louisiana Department of Public Safety and Corrections can release this information to such individuals or groups as may
be considered necessary and appropriate to determine my ability to safely operate a motor vehicle.
Signature of Patient: _______________________________
Date: __________________________
THIS SECTION IS TO BE COMPLETED BY THE OFFICE OF MOTOR VEHICLES
APPLICANT’S NAME ________________________DOB___________R/S________ DL#_______________
ADDRESS _____________________________________________________CITY______________________
DATE ISSUED_________________MVCA’S INITIALS___________BADGE #________OFFICE#________
EXAMINATION RESULTS FROM THE SNELLEN WALL CHART
WITH CARRIER LENSES:
WITH BIOPTIC TELESCOPIC LENS:
Right Eye
20/ ____________
Right Eye
20/ ______________
Left Eye
20/ ____________
Left Eye
20/ ______________
Both Eyes
20/ ____________
Both Eyes
20/ ______________
□
APPLICANT FAILED TO COMPLY WITHIN 90 DAYS
THIS SECTION IS TO BE COMPLETED BY OPTOMETRIST OR OPHTHALMOLOGIST
INSTRUCTIONS
•
The applicant must demonstrate a visual acuity of at least 20/200 in one or both eyes and a field of 110 degrees horizontal
vision without or with corrective carrier lenses. If he has vision in only one eye, he must have a field of at least 40 degrees
temporal and 30 degrees nasal horizontal vision.
•
The applicant must demonstrate a visual acuity of at least 20/60 in one or both eyes with the bioptic telescopic lenses and
without the use of field expanders.
•
The Optometrist or Ophthalmologist must certify that no ocular diagnosis or prognosis currently exists or is likely to occur
during the period of issuance of the license which would cause deterioration of visual acuity or visual field to levels below
the minimum standards.
•
This form must be completed in its entirety by an optometrist or ophthalmologist based on an examination performed within
60 days.
•
Incomplete forms may be rejected and could result in the denial of applicants driving privileges.
•
Clip on or hand-held telescopic lens are not acceptable.
PATIENT’S NAME ___________________________________________________ DOB ________________
□ Initial Evaluation □ Re-evaluation
EXAMINATION DATE _______________ (must be within 60 days)
WITH CARRIER LENSES:
WITH BIOPTIC TELESCOPIC LENS:
Right Eye
20/ ____________
Right Eye
20/ ______________
Left Eye
20/ ____________
Left Eye
20/ ______________
Both Eyes
20/ ____________
Both Eyes
20/ ______________
PERIPHERAL VISION FIELDS:
Left ____________________________________ Right ________________________________
Temporal
Nasal
Temporal
Nasal
PATIENT’S NAME ___________________________________________________ DOB ________________
1. Does the patient meet or exceed the minimum acceptable horizontal, binocular field of vision requirements. □ Yes
□ No
NOTE: Field expanders are not allowed to achieve vision requirements.
2. Can applicant recognize and distinguish among traffic control signals and devices showing standard red,
□ Yes
□ No
green and amber colors.
3. What medical conditions caused the present loss of the patient’s visual acuity?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
4. Does the patient have any progressive diseases of the eye?
□ Yes
□ No
Cataracts
□ Yes
□ No
Diabetic Retinopathy
□ Yes
□ No
Glaucoma
□ Yes
□ No
Macular Degeneration
□ Yes
□ No
Retinitis Pigmentosa
□ Yes
□ No If so, please describe. ______________________________________
Other
4. How long has this patient been under your care? ________
1. What is the date of the most recent visual examination? ___________________
2. On what date did patient receive telescopic lens? __________________
□ Yes
□ No
3. Did patient complete the prescribed training exercises for the use of the bioptic telescopic lens?
□ Yes
□ No
4. In your opinion, should the patient be restricted to “Daylight Driving Only”?
5. Can you certify that that no ocular diagnosis or prognosis currently exists or is likely to occur during the period of issuance of the
license which would cause deterioration of visual acuity or visual field to levels below the minimum standards. □ Yes
□ No
□ 6 months
□ Yearly
6. Patient should be re-evaluated every :
7. If license issued, what restrictions would be recommended.
□ 5 mile radius of home
□ 10 mile radius
□ 15 mile radius
□ 20 mile radius
□ 25 mile radius
□ No interstate highway
□ light traffic only
Other special restrictions please explain:
____________________________________________________________________________________________________________
________________________________________________________________________
□ Yes □ No
12 In your opinion, would the patient’s condition interfere with the safe operation of a motor vehicle?
If “yes”, please explain in the space provided or attach an explanation on your letterhead.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
In accordance with the provisions of R.S. 40:1356, a health care provider is exempt from any liability as a result of reporting to the
Department of Public Safety and Corrections any visual ability, physical condition, impairment or disability which may impair a
person’s ability to exercise ordinary and reasonable control in the operation of a motor vehicle. This form must be completed in its
entirety by an optometrist or ophthalmologist.
Physician’s Signature _________________________________________ Date _______________________
Physician’s Printed Name ______________________________________ Telephone # (___) _____________
Physician’s Address _______________________________________________________________________
Rev. 12/2008
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