Mississippi's Driver Service Bureau mails this vision form to a driver, along with the DR-11 medical form, in a 30-day Notice of Concern after someone reports the driver as unsafe. The ophthalmologist or optometrist records acuity and field of vision and checks one licensing opinion, which DPS medical staff review before scheduling a driving evaluation.
The driver signs the release at the top; an ophthalmologist or optometrist completes the rest, including the required opinion, and marks which of the two professions they are.
Download the current version from the source each time; forms change without notice.
Request for Statement of Vision Specialist
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
One year. The form states it is valid for one year from the date of issuance, and the DPS Medical Department page says DR-11 and DE-26 are valid for one year from the date the licensed professional completed them.
The DPS Medical Department page says the licensed professional returns DE-26 by email or mail to the Driver Records Medical Division. Medical staff review it with the DR-11, then schedule a driving evaluation with a Driver Service Bureau examiner, who relies heavily on the professional's opinion.