Bioptic Telescopic Lens Vision Examination
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2LOUISIANA 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.
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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
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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.
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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.
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This form must be completed in its entirety by an optometrist or ophthalmologist based on an examination performed within
60 days.
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Incomplete forms may be rejected and could result in the denial of applicants driving privileges.
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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
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