NOTE: This page is for information only. Download this file and have your authorized person, or yourself, complete and sign it. Once completed, you may email it, fax it, or mail to our address. Our contact information is at the bottom of this form.
ELIGIBILITY: To be eligible for this service a person must be unable to utilize ordinary print because of one or more of the following limitations:
- Visual acuity of 20/200 or less in the better eye with correction; or, blurred or double vision after normal correction, as determined by competent authority.
- Physical inability to hold a book or turn pages.
- Visual or physical impairment, extreme weakness or excessive fatigue preventing reading of printed matter.
Any of the above conditions may be certified by an authorized person, such as an ophthalmologist, optometrist, medical doctor, social worker, head of residence, or other authorized person; or you may attest to the above yourself.
I certify that (Mr. Mrs. Ms) ________________________________ has/have a visual or physical condition preventing him/her/me from reading conventional print material.
Signature__________________________________________
Authority/Self______________________________________
Title:________________________________________________
Address:____________________________________________
Phone:______________________________________________
Fax: _________________________________________________
E-mail address ______________________________________
Metropolitan Washington Ear, Inc.
12601 Tech Road
Silver Spring, MD 20904
Phone (301) 681-6636
info@washear.org