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SECTION 400 PART A: FORMS AND APPLICATION PROCESS

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REVISED: 09/20/10

DSB-2001 APPLICATION FOR EYE CARE CERTIFICATION

PURPOSE

The DSB-2001 is used to document identifying information, income and deductions. It also documents that the applicant has read the “Freedom of Choice” statement and the legal statements about misrepresentation and fraud. This application now provides a guide through the application process for both the applicant and the interviewer with space for documentation.

INSTRUCTIONS

DSB-2001, Application for Eye Care Certification

DSB-2031 LETTER TO ACCOMPANY MAILED APPLICATION

DSB-2031, Letter to Accompany Mailed Application

DSB-2032 NOTIFICATION OF NEED FOR ADDITIONAL INFORMATION

PURPOSE

The person who is determining the eligibility of the applicant for the MEC Program will complete and mail this form to the applicant if the application is not complete or if the applicant is eligible to receive eye care services from another program.

INSTRUCTIONS

DSB-2032, Notification of Need for Additional Information

DSB-2033 NOTIFICATION OF ELIGIBILITY STATUS

PURPOSE

This form letter notifies the applicant of the decision on his/her eligibility for the MEC Program if it was not possible for the interviewer to make the determination and verbally give the applicant the decision while the applicant and/or his representative was in the office.

INSTRUCTIONS

DSB-2033, Notification of Eligibility Status

DSB-2202 REPORT OF EYE EXAMINATION

PURPOSE

Form DSB-2202 is used to report the results of eye examinations conducted by physicians, ophthalmologists, and optometrists. This form provides identifying data on the individual examined, a brief medical history, and the visual acuity.

INSTRUCTIONS

These reports are to be mailed to the Nursing Eye Care Consultant in the agency’s district office. Refer to Appendix A for district offices’ mailing addresses and respective county assignments.

N.C. General Statute 111-4 requires that all individuals with the following visual acuities be listed on the North Carolina Register of the Blind:

DSB-2202, Report of Eye Examination

DSB-7219 APPLICATION FOR CONFERENCE

PURPOSE

To notify the Chief, ILS and Medical Eye Care Program and the Area Supervisor of Social Services for the Blind of a consumer’s dissatisfaction with the medical eye care program and to request a conference concerning his/her dissatisfaction.

PREPARED BY

The consumer, his/her representative, or the Social Worker for the Blind.

INSTRUCTION

DISTRIBUTION:

 

Original To: Chief, Independent Living Services Program in DSB State Office

Copies To:

DSB Area Supervisor of Social Services for the Blind

County Department of Social Services

Appellant

DSB-7219, Application for Conference

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  For questions or clarification on any of the policy contained in these manuals, please contact the local district office.


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