(Revised 2/02 ML #2776)
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This form is used by the state office to notify the county social service office of the determination of eligibility for the Aid to the Blind - Remedial Care Program. The county social service board office is responsible for notification to the applicant/recipient of the decision.
SAMPLE
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
Bismarck, North Dakota
December 22, 2001
Director
_________________ County Social Service Board
Name _____________________
_________________, North Dakota
Case No. __________________
On the basis of medical documentation and social information (SFN 451), this application for Aid to the Blind - Remedial Care is (Approved or Denied).
Submitted reports indicate that (applicant) age _____, meets the criteria for the Aid to the Blind - Remedial Care Program. The Aid to the Blind - Remedial Care is approved for the __________ eye only. A new medical report from the ophthalmologist will be required before approval for the ______ eye will be granted.
Please request the necessary authorizations from Public Assistance, ND Department of Human Services, Third Floor Judicial Wing, 600 East Boulevard Avenue, Bismarck, ND 58505-0250. Medical coverage is limited to the emergency eye condition and necessary preoperative care, such as x-rays and laboratory services. When authorizations are requested, please indicate if there is any recipient liability.
NOTE: MEDICAL ELIGIBILITY BEGINS
Enclosed please find a copy of the eligibility report approved by Dr. Henry L. Reichert, Jr., State Supervising Ophthalmologist.
Sincerely,
Administrator of Public Assistance
