NC DSB-2205-A 2007-2025 free printable template

This document is a referral form for individuals requiring low vision evaluation, used by the North Carolina Department of Health and Human Services Division of Services for the Blind. It collects

How to fill out referral for low vision

How to fill out referral for low vision

1. Gather patient information: Collect personal details such as name, date of birth, and contact information.
2. Document medical history: Include relevant medical history, previous eye examinations, and existing conditions.
3. Specify symptoms: Clearly outline the vision problems the patient is experiencing, such as difficulty reading or recognizing faces.
4. Complete referral information: Fill in the details of the referring physician, as well as the specialist to whom the patient is being referred.
5. Include additional notes: Add any necessary comments or information that may assist the specialist in understanding the patient's condition.
6. Review the referral: Double-check all entered information for accuracy and completeness.
7. Submit the referral: Send the completed referral to the appropriate specialist or healthcare provider.

Who needs referral for low vision?

1. Individuals experiencing significant vision impairment that affects their daily activities.
2. Patients diagnosed with conditions such as macular degeneration, diabetic retinopathy, or glaucoma.
3. Those unable to achieve adequate vision correction with glasses or contact lenses.
4. People with symptoms like blurred vision, blind spots, or difficulty seeing in low light.

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What is referral for low vision?

Referral for low vision is a process where a medical professional recommends a patient to a low vision specialist for further evaluation and management of visual impairments that cannot be corrected with standard glasses or contact lenses.

Who is required to file referral for low vision?

Typically, primary care physicians, ophthalmologists, or optometrists are required to file a referral for low vision when they identify a patient with significant vision loss that requires specialized care.

How to fill out referral for low vision?

Filling out a referral for low vision usually involves completing a referral form that includes the patient's personal information, medical history, a description of their visual issues, and relevant test results.

What is the purpose of referral for low vision?

The purpose of a referral for low vision is to provide patients with access to specialized care that can help maximize their remaining vision and improve their quality of life.

What information must be reported on referral for low vision?

The information that must be reported on a referral for low vision typically includes the patient's demographics, vision assessment results, clinical findings, past medical history, and any treatments or interventions already attempted.