Form 999 2026

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The document is a Vision Examination Record form used to assess a driver's or patient's visual abilities for safe motor vehicle operation. It includes sections for personal information, physician evaluation of visual acuity, and authorization for the eye examination. The form must be signed by both the patient and the physician, and it provides instructions for submission to the Driver License Bureau.

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Click ‘Get Form’ to open form 999 in the editor.
Begin by entering your Last Name, First Name, and Middle Initial in the designated fields.
Fill in your Date of Birth using the MM/DD/YYYY format and provide your Social Security Number.
Complete your Mailing Address, including City, State, and ZIP Code.
Read the authorization statement carefully and sign as the Driver or Patient in the presence of a physician. Include the date of signature.
If applicable, indicate whether you are a regular eye care provider for this patient and specify how many times you have seen them in the past year.
In the Physician Section, fill out Distance Acuity details for both eyes with or without correction as required.
Provide any remarks regarding special restrictions or conditions if necessary.
Finally, complete your Office Mailing Address and include your License Number, Phone Number, and Signature along with the date.

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