Free 12417.pdf - Indiana

PHYSICIAN'S / OPTOMETRIST'S REPORT ON EYE EXAMINATION
State Form 12417 (R4 / 6-96) OMPP 0045

The information requested on this form is needed to determine eligibility for public assistance and will be treated as a CONFIDENTIAL record according to 470 IAC 1-2-7 and 470 IAC 1-3-1.

INSTRUCTIONS:

SECTION I should be completed by the County Office of Family and Children in triplicate. Forward three (3) copies to the examining physician or optometrist. SECTION I - SOCIAL HISTORY

Name

Date of birth (month, day, year)

Sex

Case number

Address (street, city, state)

ZIP code

County

Severe ocular infections, injuries, eye operations, if any, with age or time of occurence

Is the client's eye condition believed to have occurred in any blood relatives?

If Yes, what relationship?

Has the client ever had kidney disease, high blood pressure, hardening of the arteries or diabetes?

Yes

No

Yes

No

INSTRUCTIONS: Eye Physician or Optometrist should complete SECTIONS II, III, IV and V. keep one (1) copy and return original and one (1) copy to the County Office, Division of Family and Children. SECTION II - CAUSE OF BLINDNESS OR VISUAL IMPAIRMENT O.D. O.D. O.D.

A. Physical examination of the eyes. Present ocular condition(s) responsible for vision impairment. (If more than one, specify all but underline the one which probably caused severe vision impairment.) B. Preceding ocular condition, if any, which led to present condition or the underlined condition specified in A. C. Etiology (underlying cause) of ocular condition primarily responsible for vision impairment (e.g., specific disease, injury, poisoning, heredity or other prenatal influence.)

O.S. O.S. O.S.

D. If etiology is injury or poisoning, indicate circumstances and kind of object or poison involved.

E. Has patient had any nonocular disease, not specified, which could have contributed to the visual impairment?

If Yes, specify
Instrument used

Yes

No

O.D.

Tension (if glaucoma) MM. Hg. O.S.

MM. Hg. SECTION III - VISUAL DATA

Central Visual Acuity O.D. Without Glasses O.D. With Present Glasses O.D.

Distance (20 ft.) O.S. O.S. O.S.

Distance (20 ft.)

With Best Possible Correction Refraction Record - T be recorded in all cases where refraction improves visual acuity to better than 20/200. o O.D. Sphere O.D. Cylinder O.D. Axis O.D. Bifocal Add Field Construction Is visual field constricted?
If Yes, to what degree?

O.S. O.S. O.S. O.S.

O.D. O.S.

Yes Yes

No
If Yes, to what degree?

No

SECTION IV - PROGNOSIS AND RECOMMENDATION
A. Does the patient now have suitable glasses? If No, do you recommend new glasses?

Yes
B. Patient's vision impairment is considered to be:

No Deteriorating
If Yes, to what degree?

Yes Uncertain

No

Stable
C. Will vision improve with treatment?

Yes
D. Your recommendation

No

E. If cataracts are the cause of deteriorated vision, state light projection and separation

F Is re-examination advised? .

If Yes, interval?

Yes
G. Should there be a referral?

No No SECTION V - CERTIFICATION

Yes

I certify that I have examined this patient and the fee submitted on the attached claim is lawfully due me.
Date of examination (month, day, year) Signature of eye physician or optometrist

Date report completed (month, day, year)

Typed or printed name

Address (street, city, state)

ZIP code

PLEASE MAKE NO ENTRY BELOW THIS LINE
SECTION VI - DECISION OF SUPERVISING PHYSICIAN
1. From the evidence submitted, the applicant or recipient:

is blind
Additional information is required regarding:

is not blind

2. If the person is blind:

No re-examination is required

A re-examination is required in: 3 years 1 year 2 years 6 months

3 months

Comments

Signature of supervising physician

Date signed (month, day, year)