Get the free 359A-Vision Screening Referral - Washington County School District

Washington County School District Health Services VISION SCREENING REFERRAL Dear Parent/Guardian, In accordance with Utah law 53A11203, a Vision Screening was done at school, which indicates that

How to fill out 359a-vision screening referral

How to fill out 359a-vision screening referral:

1. Obtain the form: The 359a-vision screening referral form can typically be obtained from a healthcare provider or an eye care specialist. It may also be available online through official government websites or medical resource platforms.
2. Fill out patient information: Start by providing the necessary patient information on the form. This may include the patient's full name, date of birth, contact information, and any other relevant identification details.
3. Specify referring physician: Indicate the name and contact information of the healthcare professional or physician who is referring the patient for the vision screening. This could be the patient's primary care physician or another specialist.
4. Describe reason for referral: In this section, briefly explain the reason for the vision screening referral. Be specific and include any relevant details such as symptoms, concerns, or previous medical history that may be important for the eye care provider to know.
5. Include current medications: List any medications that the patient is currently taking. This is important as some medications can affect vision or eye health, and the eye care provider should be aware of them.
6. Provide insurance information: If applicable, provide the patient's insurance information, including the insurance company name, policy number, and any necessary authorizations or referrals required by the insurance provider.
7. Sign and date the form: Ensure that the form is signed and dated by both the referring physician and the patient. This confirms that the patient is aware of and agrees to the referral for the vision screening.

Who needs a 359a-vision screening referral:

1. Individuals with visual abnormalities: Anyone experiencing visual abnormalities such as blurred vision, double vision, or difficulty seeing clearly may require a 359a-vision screening referral. This can help identify potential eye conditions or determine the need for corrective measures like glasses or contact lenses.
2. Individuals with specific medical conditions: Patients with certain medical conditions like diabetes, hypertension, autoimmune disorders, or a family history of eye diseases may need a vision screening referral for early detection and management of potential eye complications related to their condition.
3. School-aged children: Many schools require vision screenings for students, and a 359a-vision screening referral may be needed if a child's regular screening indicates a potential vision problem. This referral can help facilitate a comprehensive evaluation by an eye care specialist to ensure optimal vision health for the child's learning and development.

Note: The specific criteria for needing a 359a-vision screening referral may vary depending on local regulations, insurance policies, and the recommendations of healthcare professionals. It is always best to consult with a healthcare provider to determine if a referral is necessary in a particular situation.

For pdfFiller’s FAQs

What is 359a-vision screening referral?

359a-vision screening referral is a referral form used to document vision screening results for individuals.

Who is required to file 359a-vision screening referral?

Schools, healthcare providers, and other entities responsible for conducting vision screenings are required to file 359a-vision screening referral.

How to fill out 359a-vision screening referral?

To fill out 359a-vision screening referral, you need to include the individual's personal information, screening results, and any recommended follow-up actions.

What is the purpose of 359a-vision screening referral?

The purpose of 359a-vision screening referral is to ensure that individuals receive necessary follow-up care for any vision issues identified during screening.

What information must be reported on 359a-vision screening referral?

Information such as individual's name, date of birth, screening results, recommended follow-up actions, and contact information must be reported on 359a-vision screening referral.

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