HomeMy WebLinkAboutCOM 0696.000 1996-1998 ~._,?F ROM Marlin Spike Werner, Ph.D. ~ PHONE N0. : 1 S'~09 935 1299 dan. 27 1998 05: 34PM P1
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MARI:IN SPIKE 'bX~'ERI\ER, PhA
" -AutP~ology,$poech / Lanpteage Pathol '
400HuaWn15"Neat, 3ulte 141-4a (Witiakea IlSad)
J t HUo, i13~ Qk'J,2O<43;f9 '
' 945-Y299 (Voice) 961-3152 (FA7i 6z TTYj
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~ ~ January Z7, 1998
Councilman Dominic Yagong
25 Aupuru Street
Hilo, HI 96720
Dear Councilman Yagong
[ am writing to you to reattest that a small change be made in the wordittE; of the Cotmry of Nawali °Physhian's
Cert?Pled Report on Eye or Hoaring EsamLwtlon oPDlsablllfiv 9or Tax Exempdon Purpox~."
That tome has provision only for signatures of a "Physician, Otolary~ngologist, or 9ptometrtst."
I would like to hsve "Audiologist" added to the form. Audiologist are the experts on hearing, end are fully
qualified to determine disability according to Section 19.75 of CD1;btINANCE Number 9784, (a) (2) ""Deaf'
means a perscm whose average loss in the speech frequencies (five t~LVtdred to two tho»,sand Hem) in the better enr
is eighty-two decibels, A.S.A., or worse"
Purtherrnore, tlus definition discrimvtates against those persona ''o, whc7rn speech is garbled, as it cornmotily is in
cases of noise exposure, and a condition known as ptesbycttsis. (n effect, the inability to rnpeat a simple list of
weds ecuistitutes a serious disahilily regardless of the decibel !eve! of his'hes hearing. Herd the authority of the
audiologist exceeds that of the other disciplines addressed in the: subject application.
Hardship: Recently I had a patient came over from ICailua-Korea i:or evaluation. His right ear was tomlly deaf, and
the right side of his face paralyzed. the heating having been desb'ay°ad with the removal of a honor Priar to his
surgery he was already severely hard of heating ut both ears, s~tc! has only been able to supl,lement his lip readutg
with hints from his hearing aid Because the application for the'I'a; 'exemption, he had to get an crtolaryrtgologist's
signature on the paper. There is only one full-tine Otolaryrtgolcfi:;: rm the island, and she is in Hilo. Result? He
had to rehrm to Kcma without the signature He needs his wife 1o drive. Yam and that reQuires her to take a day off
from work Because a signature could not be obtained on the sattae day, t}utt means two &1ys off from work for her.
A disabrbty is Itatdsltip earotrglt without imposing unnecessary re :I t ,!n: ur tyre way of the applicazrt
Councilman Yagong, I hope you will be able to help out.
Sincerely yoltrs,
,
Marlin Spike Wemer, Ph.D.
lea _--Y'i-L..SG.~_
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!?ei. Ihxte ~d'tEN 2 9 1998
~ FROM Marltn Eptke Werner, Ph ~ PHONE N0. ~ 1 E0E 935 1299 Jan. 27 1998 05 35PM P2
Form 19.75A (g/97)
- - County of Hawaii -Real Property Tax Division
• Physician's Certified Report On Eye Or• Hearing
P
Exammahon Disability-for Tax Exemption Purposes I?
~ ! , : , (Completl: nl~o~pa even if applicant has multiple disabilities)
4 k
Tax Map Key Number(s) ~ ~ il~~ y''• ' ` ' i
" ~ !Applicant's Name ~ ~ ~ ~ ' ~ u~ Social Security No
Address ~ ~ =i Telephone No.'
'!i~ i
ART I EYE EXAMINATION (Must:be done by an opthalmologist or an optometrist)
a. Diagnosis
b. Vision without corrective lenses: OD: OS:
c. Vision with corrective lenses: OD• OS:
d. Is this applicant's visual acuity 20/200 or worse in the better eye with corrective lenses? ( J Yes [ ] No
e.. Is there a field defect in which the widest diameter of visual field subtends an angle no greater than
20 degrees? [ J Yes ( J No
f Date first certifiable as legally "blind"
g. Should applicant be re-examined for tax purposes? ( J 1'es [ J No If "yes", when
ART II HEARING EXAMINATION (Must be done by an otolaryngologist)
a. Diagnosis
b. Hearing loss (500-2000 Hertz) without aid' Right Left
(Decibels ASA or ANSI 1969)
Is the applicant's average loss in speech frequencies (500-2000) Hertz in the better earl
82 Decibels ASA (or 92 Decibels ANSI 1969) or worse? [ J Yes [ ] No
d. Date first certifiable as legally "deaf'
e. Should applicant be re-examined for tax purposes? [ J Yes [ ] No If "yes", when?
ART III REPORT ON DISABII.ITY (Must be done by physicians licensed under Chapter 453 or 460, HRS)
a. Diagnosis
b. Date first disabled or unable to work Date under your care (by year)
c. Diagnosis and pertinent symptoms or findings that preclude ability to engage in gainful work
d. Is the condition totally and permanently disabling? [ J Yeo [ J No
e. If "No", when should applicant be re-examined for tax purposes?
CERTIFICATION BY A LICENSED PHYSICIAN, OTOLARYNGOLOGiST OR OPTOMETRIST
Based on the above report, l hereby certiFy that:
Applicant conforms to State definition of "Blind" [ j "Deaf' [ ] or "Totally Disabled" [ J, OR
Applicant does not conform to the above definitions [
Date Signature of Physician, OWlaryngologist or Optometrist
License Number Print Name of Physician, Otolatyngologist or Optometrist
Date License 8xpirc5 Address of Physician, Otolaryngologist or Optomdnst
`kROM : Marlin Spike Werner, Ph 4 PHONE N0. : 1 808 935 1299 Jan. 27 1998 05:36PM P3
i I
'p o'
4l r rFILL OUT TWO COPIES C ,~MPLET 1 ~',CLA1M FOR EACH PARCEL OWNED)' i o
Y
RP FormT 19ES (r4%7) J Ijl ~~713(ll a, ~ a, y
~ ~ DEPT OF rtNANC t1,' t l~ <.COU ~ t ~ ~ ISLE ~ Z S PLAT PARCEL ; ' C~~P~A
~ y ? ~
„ i .^r16SR !'nG 0.A 'i967Sa'
~ ,
']SS705 hudMi~lnT~Sit: II ~ nAr. y1M HSw~I) 96730": Is tlrrs;your residence? Yes'[ jNti
~ , t ~ A6nne ~~Htuo%1 KQUA 3gi715J11 ~ lr ,y ~ 7.,.
..a~ i~ ;,f +r".,lY ~ i ~ .(For Dt~Glal USC) ~ t j~
y,1' ~ ~l Ik 1€+a ~ ~ P1TT'~
CLAIM FOR'DISABI EXEMPTION' ' ~EX C.D. f
Exemption ishereby claimed from'Real Property Tax due to'. BLDG;"/" ~
(Please theck one) ~ ~ LAND "/n '
[ J Hansen's disease stdfercr EX #
[ J Blind
' [ J Deaf ,
[ [ Totally disabled
(Print Claimant's Name) (Social Security Number) (Date of Birth)
Mailing Address
Business Phone - Residence Phone
Dated 19=
Claimant's Signature
'This exemption is in addilion to the regular home exemption. To obtain the regular home cxcmption, you must file a claim on
RP FORM 19-71- Impairment or disability must be anified by a licensed physician, otolan•ngologist or optometrist and said
certificate filed at Real Property Tax office. . _
SOCIAL SECURITY NUMBER •Tha applicant's social security number is requested for the purpose of establishing the identity
of the applicant for cxcmption and maintaining a record of exemption claims. The request is authorized under [he Cederal Social
Security Act (42 U.S.C.A. Sec. 405(c)(2)(C)). Diselosurtis voluntar} and will not affect the allowance of a Claim for exemption
but failure to disclose may rewlt in the delay in verifying eligibility Cor the claim. if disclosed, social securiq numbers will not
be subject to public access.
(F0rTax Office tine Only)
Received by: Effective Tax Year
Date 19
Input Date: BY~
~ Claim Disallowed For Tax Year Reason:
Input Date- BY -