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Patches Form (Click Here to download)Print this page. With pen, fill-out all information completely. Send application by mail to: Ohio Amblyope Registry, 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 2006 federal poverty guidelines for family size. Patients are limited to a total of 30 boxes of patches in lots of 6 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: ___________________________
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