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Vision USA Application Form

Spanish verision (Word document)

VISION USA PATIENT APPLICATION FORM

May be used for all family members. Applications are accepted year round.

VISION USA provides free eye exams to eligible, low-income working families. Services are donated by volunteer optometrists who are members of the American Optometric Association and may be limited in some areas.

COMPLETE THIS APPLICATION FORM ONLY IF:

Someone in the household is working at least part time;
The person seeking care has no public or private insurance that covers eye exams;
The person has not had an eye exam in the last 2 years;
The household is low-income and unable to pay for eye exams.

NO EXCEPTIONS WILL BE MADE

Your completed form will be reviewed to determine your eligibility. If you are qualified and a volunteer doctor is available in your area, you will be given his or her name to contact for an appointment.

You must answer all information and questions. Verification may be requested.

Please allow 3-7 weeks for determination of eligibility for the VISION USA program.

Please fill out all required fields.
1.	Is anyone in your household currently working at least part-time?
	Yes No
2.	What is the total number of people in your household living with you including yourself?
3.	What was your household's approximate gross income (before taxes and deductions) including income from other sources such as alimony and child support? Please enter whole dollar amount only. Last Month $ OR (not both) Last Year $
Names of the members of your household you want to apply for a free eye exam.

	First Name	Last Name	Has this person had an eye exam in the last two years? (School screenings are NOT considered exams.)	Does this person have any private or government insurance, Medicaid or Medicare, that covers eye exams?
1.			Yes No	Yes No
2.			Yes No	Yes No
3			Yes No	Yes No
4.			Yes No	Yes No
5.			Yes No	Yes No
6.			Yes No	Yes No
Address: Apt:
City: State: Zip:
Daytime Phone Number (area code first):
E-mail Address:

Please allow 3-7 weeks for determination of eligibility for the VISION USA program.