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Patches Form (Click Here to download)If your family income falls at or below the following guidelines, then your child qualifies to receive up to 15 additional boxes of patches!
*For families with more than 8 persons, add $6,960 for each additional person.
“O.K., my child qualifies, now what do I do?
Step 2: Attach proof of income document (see application form for acceptable documents). Step 3: Mail application form and proof of income to: Ohio Amblyope Registry Nationwide Children’s Hospital 700 Children’s Drive Columbus, OH 43205
Patches Form (Click Here to download)Print this page or download by clicking above link. With a pen, fill-out all information completely. Send application by mail to: Ohio Amblyope Registry, Nationwide Children's Hospital, 700 Children’s Drive, Columbus, OH 43205 Patient Name: _________________________________________ Parent Name(s): _______________________________________ Patient Mailing Address: ____________________________________________________ _________________________________________________________________________ Phone Number: __________-__________-__________ Patient’s birth date (month/day/year): _________/_________/________ Patient Social Security Number (required by ODH): ________-________-__________ Is the patient a resident of Ohio? ________Yes ________No What county of Ohio does the patient live in?: __________________________________ Is the patient a citizen of the USA? ________Yes ________No Annual Household income: $______________ Number of family members living in household: ________________ With the application form, submit one of the following:
Limitations: Limited to Ohio residents only. Form must be completely filled-out to be considered. Patches are restricted to those families with a household income of less than two (2) times the federal poverty guidelines for family size. Patients are limited to a total of 15 large boxes of patches in lots of 3 boxes at a time. You can call the toll-free number (1-877-808-2422) or visit the web site for the Ohio Amblyope Registry (OhioAmblyopeRegistry.com) to request additional patches. Please allow 1 week delivery time for your patches. All information is strictly confidential and for program use only. Funded by The Ohio Department of Health, Bureau of Child and Family Health Services, Save Our Sight Program. Parent or Guardian Sign Here: ______________________________________ Date: ___________________________
Reorder Patches by Clicking Here Return to Home Page Click Here This web site is funded by The Ohio Department of Health, Bureau of Child and Family Health Services, Save Our Sight Program. |