Free eye exams

Do you have healthcare insurance? Here is a program for those who don't have insurance and need an eye exam and possibly glasses.

http://www.aoa.org/x5611.xml

This form not to be used for application in Arizona, California, Colorado, Hawaii, Kansas, Kentucky, Minnesota, Montana, North Dakota, Wisconsin and Wyoming.

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. The application is also available in Spanish, click here to download. If you are unable to download the applications, both are available as Word document files by requesting them from visionusa@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:

1.Someone in the household is working at least part time;
2.The person seeking care has no public or private insurance that covers eye exams;
3.The person has not had an eye exam in the last 2 years;
4.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.