Vision USA Hawaii Project - Year Round Program

Vision USA optometrists, members of the Hawaii Optometric Association, will provide basic eye health and vision care services to individuals and families, who may not qualify for government aid or private health care assistance. Eligible patients will receive a basic eye exam, and in some cases, eyeglasses without cost.

Vision USA  Hawaii Project
~ Patient Application Form ~
"Year Round Program"




This application serves as a request for services for:  Applicant  Spouse  Dependent(s)
If you are filling this form out for yourself, as well as other members of your household, please list all other household members in need of assistance on the back of this application.

Please Print All Information Clearly

Applicant's Name: ___________________________________ Social Security #: ___________________

Address: ________________________________ City: _______________ State: ____ Zip: _________


Hawaii Resident:  Yes  No Years Lived in the State of Hawaii: ______

Date of Birth: __________ # of Dependents in Household (including self): ____ Spouses Name: ____________
Home/Cell Phone: ______________________ E-mail Address: _________________________

Employer (Applicant or Spouses): ____________________________ Work Phone: __________________

Are you or your family covered under any health insurance or assistance program, including Medicaid?
Medicare and/or other Health Services?  Yes  No

If yes, which plan or program(s)? ________________________________________________

Have you used the Vision USA Program in the past?  Yes  No If yes, what year did you use it? _____

When was your last eye exam? ______________ Who was your last eye doctor? _______________

Where was your last eye exam? _____________ Do you presently have eyeglasses?  Yes  No
Briefly describe why assistance is needed: _____________________________________________________________
Instructions: The following information will be held confidential and is only provided to the Hawaii Optometric Association, or other sponsoring agencies of Vision USA - Hawaii Project entity. The information will be used to determine eligibility to receive assistance for eyecare.

MONTHLY HOUSEHOLD RESOURCES:

Monthly Net Income: _______________ Savings: _____________ Real Property: ________________

Other (Including child support, workers comp, disability, social security, food stamps, etc.):_____________________

TOTAL MONTHLY INCOME: _________________________

MONTHLY HOUSEHOLD EXPRENSES:

Rent/Mortgage: ____________ Telephone/cell: _________ Utilities: _________ Food Costs: _____________

Transportation: _____________ Vehicle(s) Payment: ___________ Home Insurance: _________

Medical Expenses: ___________Real Estate Taxes: _________ Life Insurance: _________

Child Care Expenses: ______________ Other: ______________

TOTAL MONTHLY EXPENSES: ____________________

Please list a third party that can verify your need for assistance. (THIS FORM MUST BE VERIFIED by a Vision USA Participating Provider, Social Service Center, Clergy, Teacher or Employer. FAMILY OR FRIEND REFERENCES DO NOT QUALIFY.) Applications lacking verification by a Third Party will NOT BE PROCESSED.

Third Party Name: _________________________ Phone: ____________ Address: _________________

Title/Occupation of Third Party: ____________________ E-mail Address: __________________________

_________________________________


Applicants Signature: _______________________ Date: ____________

Additional Family Members

Family members must be living in the household, be a dependent according to state/federal tax authorities and in need of assistance. Other relatives or persons need to fill out a separate application. Please limit your request to 3 exams per household.

Name of Family Member: ____________________ Date of Birth: _________________ Last Eye Exam: _________

Name of Family Member: ____________________ Date of Birth: _________________ Last Eye Exam: _________

Name of Family Member: ____________________ Date of Birth: _________________ Last Eye Exam: _________

Return Completed Form To:

Hawaii Optometric Association – Vision USA Project

220 South King Street, Suite 801 Honolulu, HI 96813
FAX: 537-1509 Telephone: 537-5678