OCFS-4599 (Rev 10/2013)

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Commission for the Blind

REPORT OF LEGAL BLINDNESS-REQUEST FOR INFORMATION

 

PART A -Please complete this information in full in order to avoid delay in registration of the patient and/or receipt of information requested.

REPORT OF LEGAL BLINDNESS: (Complete this part to report legal blindness)

PATIENT INFORMATION


EXAMINER

Please check the appropriate condition and cause: (Optometrist not required to indicate cause)

CONDITION






CAUSE









For individuals under 18, The Name and Address of the Parent/Guardian is Required:

Submitter (If different from above)

PART B - REQUEST FOR INFORMATION: (Complete this section if the individual is seeking information from NYSCB)






REPORT OF LEGAL BLINDNESS - PART A - (To be completed by Opthalmologist, Optometrist or other Physician)

The Eye Report section of this form is to be completed for all persons who meet the following criteria for legal blindness:

Central Visual Acuity of 20/200 or less in the better eye with the use of a corrective lens OR

A limitation in the visual field, in the better eye, less than 20 degrees.

REQUEST FOR INFORMATION - PART B - (To be completed by or for a legally blind individual)

In addition to reporting to NYSCB that this person is legally blind, we would like you to ask your patient if he/she is experiencing any difficulties performing tasks or activities. If so, please assist or have the patient complete the bottom portion on the top of this form and advise him/her that it will be forwarded to NYSCB. Then, please forward the form to the NYSCB office listed below that serves the County/Borough in which this individual resides. Your patient will be contacted about rehabilitation services.

Counties Served

Send to: NYSCB, Ellicott Square Building, 295 Main Street, Room 545, Buffalo NY 14203

Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Livingston, Monroe, Niagara, Ontario, Orleans, Steuben, Wayne, Wyoming, Yates.

Send to: NYSCB, 40 North Pearl Street, 15th Floor, Albany, New York 12243

Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton, Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga Schenectady, Schoharie, St. Lawrence (Adults), Warren, Washington.

Send to: NYSCB, The Atrium, Suite 105, 100 South Salina Street, Syracuse, New York, 13202

Broome, Cayuga, Chemung, Chenango, Cortland, Herkimer, Jefferson, Lewis, Madison, Oneida, Onondaga, Oswego, Schuyler, Seneca, St. Lawrence (Children), Tioga, Tompkins.

Send to: NYSCB, 445 Hamilton Avenue, Room 503, White Plains, New York, 10601.

Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester.

Send to: NYSCB, 50 Clinton Street, Suite 208, Hempstead, New York, 11550.

Nassau, Suffolk, Queens (Central and Eastern)

Send to: NYSCB, 80 Maiden Lane, 23rd Floor, New York, New York, 10038

Bouroughs Served: Brooklyn, Manhattan (up to and including 23rd Street), Staten Island

Send to: NYSCB, 163 West 125th Street, Room 209, New York, New York, 10027

Bouroughs Served: Bronx, Queens (Western), Manhattan (North of 23rd Street)

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