Legal Blindness Form PDF Details

The Confirmation of Legal Blindness form plays a critical role for individuals seeking to establish their status under the specific criteria set by federal guidelines. Within the framework of the Supplemental Security Income program under Title XVI of the Social Security Act, legal blindness is meticulously defined. This definition is pivotal not only for medical certification but also for various benefits and accommodations. The form requires detailed personal information from the consumer, client, or patient, including their name, date of birth, and address, alongside their visual acuity measurements with and without correction, and the extent of their visual field. It is crucial for accurately documenting an individual's visual condition, including the best corrected vision of each eye independently and both eyes together, as well as the width of the visual field in degrees and specific eye conditions. A certifying authority, typically a qualified healthcare professional, must affirm the individual's legal blindness according to the federal definition, underscoring the form's significance in providing a standardized method for this confirmation. This form not only facilitates access to necessary supports and services but also standardizes the recognition of legal blindness across various systems, safeguarding the rights and benefits of those affected.

QuestionAnswer
Form NameLegal Blindness Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesblind legally forms, legally blind forms, forms blind legally, confirmation of legal blindness form

Form Preview Example

CONFIRMATION OF LEGAL BLINDNESS

The federal definition [10] of "blindness" in the Supplemental Security Income program under Title XVI of the Social Security Act currently states:

(2)"An individual shall be considered to be blind for purposes of this title if he has central visual acuity of 20/200 or less in the better eye with the use of a correcting lens. An eye which is accompanied by a limitation in the fields of vision such that the widest diameter of the visual field subtends an angle no greater than 20 degrees shall be considered for purposes of the first sentence of this subsection as having a central visual acuity of 20/200 or less. http://www.ssa.gov/OP_Home/ssact/title16b/1614.htm

Translation: If you wear your glasses or contacts (or both) and then are measured on an eye chart as seeing 20/200 or less, or if the width of vision for both your eyes totals an arc of 20 degrees or less, you are legally blind according to this federal definition.

CONSUMER / CLIENT / PATIENT:

Name: __________________________________________ Date of Birth: ________

Address: _____________________________________________________________

Best corrected vision:

OD (right eye) _________ OS (left eye) _________ OU (both eyes _________

Width of Visual Field (in degrees): ____________

Specific eye condition(s):_______________________________________________

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CERTIFYING AUTHORITY:

I certify that ___________________________ is legally blind in both eyes

as specified in the federal definition quoted above.

(Signed) ______________________________________ (Date) _________.

(Title) _____________________________________________

Please attach your business card OR print/type your name, profession, and address here:

How to Edit Legal Blindness Form Online for Free

We used the top-rated computer programmers to develop the PDF editor. The app will allow you to prepare the forms legally blind form with no trouble and won't consume too much of your time and effort. This straightforward guide will enable you to learn how to start.

Step 1: Press the orange button "Get Form Here" on the website page.

Step 2: You'll find all the actions which you can take on the document once you've got entered the forms legally blind editing page.

You should provide the following details to complete the forms legally blind PDF:

part 1 to writing confirmation of blindnss

Complete the Best corrected vision OD right eye, Width of Visual Field in degrees, I certify that is legally blind, Signed Date, Title, and Please attach your business card section with the information demanded by the program.

confirmation of blindnss Best corrected vision OD right eye, Width of Visual Field in degrees, I certify that  is legally blind, Signed  Date, Title, and Please attach your business card fields to insert

Step 3: When you hit the Done button, your finalized document can be transferred to any of your devices or to email chosen by you.

Step 4: It will be better to have duplicates of the file. You can rest assured that we are not going to publish or view your data.

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