Get the free Low Vision Referral Low Vision Referral

Department for Children and Families Rehabilitation Services LOW VISION REFERRAL (to be completed by RS Staff) Name: Date: Address: Case Manager: Phone: Telephone: Send Report to the following address:

How to fill out low vision referral low

How to fill out a low vision referral form:

1. Begin by providing your personal information, including your name, contact details, and date of birth, as well as any other relevant identification information requested on the form.
2. Next, indicate the reason for seeking a low vision referral. This could be due to a diagnosed visual impairment or a progressive vision loss that requires specialized assistance.
3. Specify your current visual acuity and any functional limitations you experience as a result of your vision impairment. This may include difficulties with reading, mobility, or performing daily tasks.
4. If you have already received any previous vision assessments or interventions, be sure to note these in the appropriate sections. Include the names and contact information of any eye care professionals or specialists you have consulted.
5. Describe any specific visual aids or assistive devices that you currently use or are interested in exploring. Provide details about the features or functionalities you are seeking to enhance your visual functioning.
6. Indicate any other pertinent medical conditions or diagnoses that may impact your vision or the effectiveness of low vision services.
7. Finally, sign and date the form to validate the information provided.

Who needs a low vision referral form?

1. Individuals with diagnosed visual impairments who require specialized assistance to maximize their remaining vision.
2. People experiencing progressive vision loss who would benefit from low vision services and interventions.
3. Individuals who have received standard eyeglasses or contact lenses but still struggle with daily visual tasks and activities.
4. Those seeking access to visual aids or assistive technologies that can improve their visual functioning and overall quality of life.
5. Anyone who wishes to explore available resources, support, and intervention options for managing their vision impairment.

For pdfFiller’s FAQs

What is low vision referral low?

Low vision referral law refers to the legislation that outlines the requirements and procedures for referring individuals with low vision to appropriate resources for help.

Who is required to file low vision referral low?

Low vision referral law typically requires healthcare professionals such as doctors and optometrists to file referrals for individuals with low vision.

How to fill out low vision referral low?

To fill out a low vision referral form, healthcare professionals need to provide detailed information about the individual's vision impairment and recommend appropriate resources for assistance.

What is the purpose of low vision referral low?

The purpose of low vision referral law is to ensure that individuals with low vision receive the necessary support and resources to help them manage their condition effectively.

What information must be reported on low vision referral low?

Information that must be reported on a low vision referral form typically includes the individual's diagnosis, recommended resources, and contact information.

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