Get Besb Eye Report Form - Ct.gov - Ct

Filling out the BESB Eye Report Form is an essential process for reporting legally blind individuals in the state of Connecticut. This guide provides step-by-step instructions to help you complete the form accurately and effectively.

Follow the steps to successfully fill out the BESB Eye Report Form.

1. Press the ‘Get Form’ button to retrieve the BESB Eye Report Form and open it in your document editor.
2. Begin by entering the patient's name in the designated field, ensuring you include the first, middle, and last name clearly.
3. Fill in the patient's address, including city, state, and zip code. This section must be completed accurately for correspondence purposes.
4. Record the patient's date of birth in the specified format, then indicate their gender by selecting either 'F' for female or 'M' for male.
5. Provide the patient's Social Security number in the appropriate field, followed by their telephone number(s), including a contact person if applicable.
6. Address any field limitations if they exist, marking 'Yes' or 'No' in the corresponding boxes. If 'Yes', specify the degrees of limitation for each eye (OD and OS).
7. Indicate if the patient is legally blind by selecting 'Yes' or 'No'. If the patient is a child who meets the legal definition of visual impairment, please note this as well.
8. In the diagnosis section, record the ICD code as necessary, and provide the prognosis by selecting one of the options: stable, deteriorating, guarded, recovering, or unknown.
9. List any additional disabilities that may affect rehabilitation in the remarks/recommendations section.
10. Complete the date of exam, name, and address of the examining doctor. Ensure the doctor's signature is included along with their contact phone number.
11. Finally, review the entire form for accuracy. Once confirmed, save your changes, and choose to download, print, or share the form as necessary.

Get started now to complete your BESB Eye Report Form online.