Michigan DHS-49-I Eye Examination Report (MDHHS)

Michigan's Disability Determination Service (DDS) decides blindness claims for State Disability Assistance and Medicaid, and the DHS-49-I is the eye examination report it uses as evidence. The eye examiner reports the examination findings, which DDS compares with Michigan's blindness standard: acuity in the better eye correctable only to 20/200 or less, or a visual field of 20 degrees or less.

Who completes it

An ophthalmologist or optometrist completes the whole report. Michigan accepts blindness evidence from a board-certified ophthalmologist, a licensed optometrist, or an M.D. or D.O. who is an ophthalmology resident or eligible for the ophthalmology boards.

Submitting and payment

How to submit it
Return it to the DDS or MDHHS local office that sent it; the form is issued per case and is not posted publicly.
Who pays
Michigan's eligibility manual (BEM 260) says MDHHS helps clients obtain medical evidence when they need it, which can include paying for the medical evidence.

Good to know

  • Blindness means visual acuity in the better eye correctable only to 20/200 or less, or a widest visual field diameter in the better eye of 20 degrees or less.
  • A final Social Security determination that the person is not blind for SSI generally takes precedence over a DDS decision for Michigan Medicaid.
  • A client who refuses or fails to attend an exam needed to decide blindness cannot be found blind, according to BEM 260.
  • Physical and mental conditions use the DHS-49 and DHS-49-D/E; DDS records its decision on the DHS-49-A.

Get the official form

Download the current version from the source each time; forms change without notice.

Eye Examination Report

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What is the blindness standard for Michigan's DHS-49-I?

Michigan's eligibility manual defines a person as blind when the visual acuity in the better eye can only be corrected to 20/200 or less, or when the widest diameter of the visual field in the better eye is limited to an angle of 20 degrees or less.

Who can complete Michigan's Eye Examination Report?

Medical evidence of blindness must be based on the findings of a board-certified ophthalmologist, a licensed optometrist, an M.D. or D.O. resident in ophthalmology, or an M.D. or D.O. eligible to sit the ophthalmology boards. The examiner returns the report to the office that sent it.

Who pays for the DHS-49-I eye exam?

The client is responsible for providing evidence of blindness, but Michigan's eligibility manual says MDHHS assists clients who request or need help, including scheduling medical exam appointments and paying for medical evidence and medical transportation.