New Hampshire's Disability Determination Unit uses this report from an ophthalmologist or optometrist to decide eligibility for Aid to the Needy Blind (ANB) cash and medical assistance. Page one holds the applicant's release of eye records to DHHS; the examiner then documents history, best-corrected acuity, visual fields, tonometry, refraction, diagnosis for each eye, prognosis and recommendations.
The ophthalmologist or optometrist completes the history, physical examination, diagnosis and prognosis sections and signs with exam and report dates. The applicant, a parent of a minor, a guardian or another authorized representative signs the release, which is valid for 12 months.
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Report of Eye Examination / Authorization for Release of Medical Information
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The authorization on the form says the information will be used to determine the applicant's eligibility for Aid to the Needy Blind (ANB) cash and medical assistance. The DHHS Disability Determination Unit reviews the eye history, examination findings, diagnosis, prognosis and recommendations.
The instructions to the ophthalmologist or optometrist say to bill on the usual Medicaid invoice if the patient presents a Medicaid ID card. If the patient does not have a Medicaid ID card, submit the bill along with the completed report.
Yes, when fields are abnormal. The form states field measurements must be accompanied by field charts, and asks you to describe the type and size of target and the test distance, along with the widest diameter in degrees of remaining visual fields for each eye.