Form Ocfs 4599 PDF Details

Form Ocfs 4599 is a request for information form that can be used to collect data from individuals who have contact with a child. The form can be used to gather information about the nature and extent of the contact, as well as any other relevant information. The form is typically used by local social services agencies in order to assess the risk to a child. completed this form can help agencies make decisions about what interventions may be necessary to protect the child.

QuestionAnswer
Form NameForm Ocfs 4599
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesreport for legally blind, report of legal blindness form, legal blindness form 4599, report for legal blindness ny state

Form Preview Example

OCFS-4599 (Rev. 07/2019)

Page 1 of 2

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

REPORT OF LEGAL BLINDNESS / REQUEST FOR INFORMATION

NEW YORK STATE COMMISSION FOR THE BLIND (NYSCB)

Please complete this information in full to avoid delay in registration of the patient and/or receipt of the information requested. (Please print clearly.)

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

PATIENT INFORMATION:

LAST NAME:

FIRST NAME:

M

SE

BIRTH DATE:

SOCIAL SECURITY NUMBER:

     

     

I

X

   /   /    

     

STREET ADDRESS:

 

 

 

 

PHONE NUMBER:

 

 

 

 

     

 

 

 

 

(     )       -      

CITY:

STATE:

ZIP CODE:

 

 

COUNTY OR NYC BOROUGH:

     

NY

     

 

 

     

EXAMINER: PLEASE CHECK THE APPROPRIATE CONDITION AND CAUSE:

1.

2.

CONDITION

 

Blindness in both eyes; no light perception.

1.

A visual acuity of 20/200 or less in the better eye with

2.

best correction.

 

CAUSE

Cataracts

Glaucoma

3.

4.

5.

A visual field of no greater than 20 degrees in the better eye.

This person functions at the definition of legal blindness due to a vision condition such as cortical visual impairment. Standard acuity testing is impossible or unreliable and, in my medical opinion, the functional vision meets the definition of legal blindness.

This person was registered as legally blind, and is now not legally blind. (If so, please check Cause #7.)

3.

4.

5.

6.

All other diseases:      

Congenital condition

Accident, poisoning, exposure, or injury

Unspecified cause

PART A

6. This person is employed and is expected to become

7. Improved vision

 

 

legally blind within the year.

 

 

 

 

VISION DIAGNOSIS:     

 

 

 

 

EXAMINER LAST NAME:

FIRST NAME:

PROFESSION OF EXAMINER:

EXAM DATE:

     

     

Ophthalmologist

Optometrist

   /    /      

 

 

 

 

 

Physician

 

 

STREET ADDRESS:

 

 

 

 

     

 

 

 

 

CITY:

STATE:

ZIP CODE:

PHONE NUMBER:

 

     

   

     

(     )       -      

EXAMINER SIGNATURE:

 

 

 

 

X

 

 

 

 

FOR INDIVIDUALS UNDER 18, THE NAME AND ADDRESS OF THE PARENT/GUARDIAN IS REQUIRED:

 

PARENT/GUARDIAN: LAST NAME

 

FIRST NAME:

 

 

     

 

     

 

 

STREET ADDRESS:

 

 

 

 

     

 

 

 

 

CITY:

STATE

ZIP CODE:

PHONE NUMBER:

 

     

   

     

(     )       -      

SUBMITTER (IF DIFFERENT FROM ABOVE):

 

 

 

SUBMITTER: LAST NAME

 

FIRST NAME:

 

 

     

 

     

 

 

STREET ADDRESS:

 

 

 

 

     

 

 

 

 

CITY:

STATE

ZIP CODE:

PHONE NUMBER:

 

     

   

     

(     )       -      

REQUEST FOR INFORMATION: Complete this section if the individual is seeking information from the New York State Commission for the Blind (NYSCB).

PART B

How I can perform household tasks

How NYSCB can assist me in preparing for a job How NYSCB can assist me in keeping my current job

How NYSCB can assist in providing services to the above named legally blind child Other services (specify):      

CONTACT PERSON (PATIENT/SUBMITTER) (Please Print):

PHONE NUMBER:

     

(     )       -      

OCFS-4599 (Rev. 07/2019)

Page 2 of 2

REPORT OF LEGAL BLINDNESS (Part A)

(To be completed by ophthalmologist, optometrist or another physician)

This section is to be completed for all persons who meet at least one of the conditions (1-6) listed on Page 1:

REQUEST FOR INFORMATION (Part B)

(To be completed by, or for, a legally blind individual)

In addition to completing Part A, please ask your patient if they are experiencing any difficulties performing tasks or activities. If so, please assist or have the patient complete Part B and advise them the form will be forwarded to NYSCB.

Forward the completed form to the NYSCB office listed below that serves the county/borough in which this patient resides. The patient will then be contacted about rehabilitation services.

Counties Served

Send To:

Counties Served

 

 

 

Send To:

Allegany

Cattaraugus

Chautauqua

Erie

Genesee

Livingston

Monroe

Niagara

Ontario

Orleans

Steuben

Wayne

Wyoming

Yates

Albany

Clinton

Columbia

Delaware

Essex

Franklin

Fulton

Greene

Hamilton

Montgomery

Otsego

Rensselaer

Saratoga

Schenectady

Schoharie

St. Lawrence (Adults)

Warren

Washington

NYSCB

Ellicott Square Building

295 Main St.

Suite 545

Buffalo, NY 14203

Phone: (716) 847-3516

NYSCB

Albany District Office

52 Washington St.

Rensselaer, NY 12144

Phone: (518) 473-1675

Broome

Cayuga

Chemung

Chenango

Cortland

Herkimer

Jefferson

Lewis

Madison

Oneida

Onondaga

Oswego

Schuyler

Seneca

St Lawrence (Children)

Tioga

Tompkins

Dutchess

Orange

Putnam

Rockland

Sullivan

Ulster

Westchester

Nassau

Suffolk

Queens (Central & Eastern)

Boroughs Served

Brooklyn Manhattan (up to and including 23rd St.)

Staten Island

NYSCB

The Atrium

100 South Salina St.

Suite 105

Syracuse, NY 13202

Phone: (315) 423-5417

NYSCB

117 East Stevens Ave.

Suite 300

Valhalla, NY 10595

Phone: (914) 993-5370

NYSCB

711 Stewart Ave.

Suite 210

Garden City, NY 11530

Phone: (516) 743-4188

NYSCB

80 Maiden Lane

Suite 401

New York, NY 10038

Phone: (212) 825-5710

Visit our website for additional

information and resources.

visionloss.nv.gov

Bronx

Queens (Western)

Manhattan (North of 23rd

St.)

NYSCB

163 W. 125th St.

Suite 1315

New York, NY 10027

Phone: (212) 961-4440

Form Ocfs 4599 isn’t the one you’re looking for?

Related Documents