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11-13-2002, 05:33 PM
http://www.aoa.org/visionusa/form.asp
VISION USA PATIENT APPLICATION FORM
This form not to be used for application in Arizona, California, Colorado, Hawaii, Kansas, Kentucky, Montana, North Dakota, Rhode Island, Wisconsin and Wyoming. (Different form to click on)
May be used for all family members. Applications are accepted year round.
If you prefer to fax or mail your application, click here to download the Vision USA Patient Application Form PDF. You may make copies if you need to distribute more forms. If you are unable to download the application, or if you want a Spanish version, both are available as a word document attachment by requesting it from crglick@aoa.org.
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
VISION USA PATIENT APPLICATION FORM
This form not to be used for application in Arizona, California, Colorado, Hawaii, Kansas, Kentucky, Montana, North Dakota, Rhode Island, Wisconsin and Wyoming. (Different form to click on)
May be used for all family members. Applications are accepted year round.
If you prefer to fax or mail your application, click here to download the Vision USA Patient Application Form PDF. You may make copies if you need to distribute more forms. If you are unable to download the application, or if you want a Spanish version, both are available as a word document attachment by requesting it from crglick@aoa.org.
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