Eye Care Team - DMV Mandatory Impairment Referral Form

The Oregon DMV's Mandatory Reporting Rules (OAR 735-074-0045) became effective state-wide on June 1, 2004. Visual impairment is one of thirteen impairments that mandate reporting by Oregon health care providers under the new law. The degree of vision impairment that requires reporting is either a best corrected visual acuity of worse than 20/70 in the better of the two eyes and/or a horizontal binocular visual field of less than 110 degrees with a Goldman III4e equivalent target.

The Portland VA Medical Center Eye Care Team has adopted the following policy for reporting visual impairment.

1. The Portland VA Medical Center eye care provider will complete the DMV Mandatory Impairment Referral Form for any Portland VAMC Eye Care Team patient (Portland or Vancouver Division), regardless of the patient's state of residence, if they fail to meet the Oregon DMV's minimum visual acuity and / or field of vision requirements.
2. If the patient has a primary care provider (PCP), the PCP will be notified that the DMV Mandatory Impairment Referral Form has been completed due to visual impairment. This notification will be made through the additional signer function if the PCP is within the VISN 20 VA health care network. If the patient has a private PCP, a letter will be mailed to the PCP.
3. A hardcopy of the completed Mandatory Impairment Referral Form will be scanned into VISTA Imaging as an attachment to the patient's eye care progress note.
4. A hardcopy of the completed Mandatory Impairment Referral Form will be mailed to Release of Information (P-2-CIS / Attention: Brian Roth). ROI will mail the completed form to the DMV.

Fillable version of the DMV Mandatory Impairment Referral Form

Adobe Reader for PDF files is available here.