Vision Services Application Form

Medical Information
Check if you have or have had any of the following:

GlaucomaDiabetesHypertensionCataracts
I fully understand that Lighthouse services are limited to residents unable to pay for, or receive from other sources, this assistance. In consideration of these services, I release and discharge all persons rendering such services from any claims I may have arising from the services rendered. I am aware that the Lighthouse will not pay for any eyeglasses billed to me prior to approval of this application. I also understand that my application will be reviewed by a Lighthouse Provider, and/or the Lighthouse staff. ALL INFORMATION ON AND ATTACHED TO THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature*

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Date*

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I understand that the Federal Privacy Rule “HIPAA” does protect the privacy of information if re-disclose, and therefore request that all information obtained by this person or agency be held strictly confidential and not be further released by the recipient. I further understand that my eligibility for Lighthouse services is not conditioned upon my provision of this authorization. I intend for this document to be a valid authorization conforming to all requirements of the Privacy Rule and understand that my authorization will remain in effect for one year.
Signature*

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Date*

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Date
Complete this section only if you would like to give us permission to speak to someone else on your behalf regarding services.
Representative Name

First NameLast Name
Representative Phone Number
Please enter a valid phone number.
Relationship to Applicant

Photo Identification*

Provide ONE: Valid Driver’s License, State Photo ID, Valid Passport, Valid School Picture ID, Consulate ID card, Birth Certificate (ages 19 and under)
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Proof of Residency*

Provide ONE: Current Copy of Lease Agreement, Current Copy of Mortgage Statement, Utility Bill (Current w/in 3 mo.), Signed Letter from Shelter, Letter from Nursing Home
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Proof of Income*

Provide ONE: 2 Current Consecutive Pay Stubs for bi-weekly, Last 3 mo. Bank Statements (SSI or SSA), Official Tax Transcript/Tax Return Current Year, Social Security/Disability Award Letter, Non Filing Letter IRS, College/University Scholarship, Grant, Fellowship, Assistantship, Regular Payments from Alimony, Child Support, Unemployment, Union, Funds, Retirement or other Government Program
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Other Required Documents

If you are seeking assistance for eyeglasses only, please attach a copy of your current visionprescription. Your prescription must not be more than 2 years old.
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Vision Services Application

Medical Information

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