Get Application For Older Individuals Who Are Blind Program

This guide is designed to assist users in completing the APPLICATION FOR OLDER INDIVIDUALS WHO ARE BLIND PROGRAM form online. By following the step-by-step instructions, users can easily navigate each section of the form to ensure it is filled out correctly.

Follow the steps to successfully complete the application form.

1. Press the 'Get Form' button to access the application form and open it in your preferred editor.
2. Fill in your personal information in the name section, including your first name, middle initial, and last name.
3. Provide your residential address, including your city, state, and ZIP code.
4. Enter your contact number and Social Security number in the specified fields.
5. Indicate your date of birth and your voter registration status by selecting the appropriate option.
6. Detail your race and marital status in the corresponding fields.
7. Describe your vision problem and indicate the date of onset for this issue.
8. Respond to whether you have previously applied for rehabilitation or low vision services, and if so, provide the location and date.
9. Explain how you were referred to the Bureau of Services to the Blind and Visually Impaired (BSBVI) and specify how BSBVI can assist you.
10. Indicate if you currently drive and describe your current transportation method.
11. Fill in emergency contact information, including the name, relationship, address, and phone number.
12. List household members by including their names, ages, relationships to you, and occupations.
13. Provide information about your education, highest level attained, past professions, and reasons for leaving those jobs.
14. Indicate your interest in employment and whether you are a veteran.
15. Provide details about your private insurance and Medicare/Medicaid coverage status.
16. Complete the health survey section by describing your vision, limitations, treatments received, and equipment used.
17. Review the sections on personal information consent, prior authorization statement, client financial participation, and the Client Assistance Program.
18. Sign and date the application. If assistance was needed, ensure that the assistant also signs.
19. Once all sections are completed, save your changes, download the form, print it, or share it as needed.

Take the next step towards accessing the services you need by completing your application online today.