Missouri IM-68 Visual Disability Examination Report

Missouri decides blindness for Blind Pension, Supplemental Aid to the Blind and blindness-based MO HealthNet through a State Supervising Ophthalmologist, not the local office. The Family Support Division sends the IM-68 to the eye examiner with the appointment. The examiner records visual acuity, visual fields and eye findings, and the ophthalmologist reviews the report and decides.

Who completes it

An ophthalmologist, optometrist or physician skilled in diseases of the eye who accepts the Medicaid rate completes the middle examination section. Family Support Division staff complete the top and bottom.

Submitting and payment

How to submit it
Return the completed report to the Family Support Division, which forwards it to the State Supervising Ophthalmologist or the Medical Review Team for the decision.
Who pays
The Family Support Division pays for the examination at the Medicaid rate, with an additional trip payment when the examiner sees a claimant at home who cannot travel.

Good to know

  • Examiners must accept the Medicaid rate, as section 209.040.2 RSMo requires for these blindness examinations.
  • If the State Supervising Ophthalmologist finds the claimant eligible, they also set the date of the next eye examination.
  • When the State Supervising Ophthalmologist recommends another exam, FSD may designate a second examiner.
  • For Medical Review Team cases, the IM-68 travels with the MRT packet, including the IM61 checklist and IM61C disability questionnaire.

Get the official form

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

Visual Disability 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

Who decides blindness on Missouri's IM-68?

The State Supervising Ophthalmologist. FSD submits the completed examination report for review and decision. If the claimant is found ineligible, the application is rejected or the case closed; if eligible, the ophthalmologist sets the date of the next examination.

Can the IM-68 exam be done at the patient's home?

Yes. If the claimant cannot travel, FSD may arrange an examiner who is willing to examine the claimant at home and pays an additional amount to cover the trip. Otherwise the claimant normally provides their own transportation to the examiner.

Where do I get the IM-68?

From the Family Support Division. It is not posted as a public PDF; FSD sends the visual examination form to the examiner with the appointment, filling in the top and bottom sections itself, and the examiner completes only the examination section.