Get the free Low Vision Referral Form - The Chicago Lighthouse - chicagolighthouse
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N RUTH The Chicago Lighthouse Low Vision Clinic 1850 W. Roosevelt Rd. Chicago, IL 60608 Tel: (312) 9973686 Fax: (312) 9973663 The Chicago Lighthouse Vision Rehabilitation Center 222 Waukegan Rd. Glenview,
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How to fill out low vision referral form
How to fill out low vision referral form:
01
Start by entering your personal information, including your full name, address, phone number, and date of birth.
02
Provide your insurance information, including the name of your insurance provider and your policy number.
03
Indicate the reason for your referral for low vision services. This may include conditions such as macular degeneration, diabetic retinopathy, or glaucoma.
04
Specify any previous treatments or interventions you have received for your vision impairment.
05
If applicable, list any visual aids or assistive devices you currently use or have used in the past. This can include glasses, magnifiers, or electronic devices.
06
Mention any additional medical conditions or disabilities that may be relevant to your vision impairment.
07
If you have been referred by a healthcare professional, provide their name, contact information, and their specialty.
08
Finally, review the completed form for accuracy and make sure all required fields are filled out properly.
Who needs the low vision referral form:
01
Individuals with vision impairments who require specialized low vision services.
02
Patients diagnosed with conditions such as macular degeneration, diabetic retinopathy, glaucoma, or any other condition that causes significant visual impairment.
03
People who experience difficulty with daily tasks due to their visual impairment and require interventions or aids to improve their quality of life.
04
Individuals seeking options for visual rehabilitation and assistance in maximizing their remaining vision.
05
Patients referred by ophthalmologists, optometrists, or other healthcare professionals familiar with low vision services and the available resources.
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What is low vision referral form?
The low vision referral form is a document used to refer individuals with visual impairments to eye care professionals for further evaluation and treatment.
Who is required to file low vision referral form?
Healthcare professionals, educators, or family members who suspect an individual may have low vision are required to file the referral form.
How to fill out low vision referral form?
The low vision referral form can be filled out by providing relevant information about the individual suspected of having low vision, including their medical history, symptoms, and contact information.
What is the purpose of low vision referral form?
The purpose of the low vision referral form is to facilitate the timely evaluation and treatment of individuals with visual impairments by eye care professionals.
What information must be reported on low vision referral form?
Information such as the individual's medical history, symptoms, contact information, and any relevant test results must be reported on the low vision referral form.
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