Vision USA Application Form
VISION USA PATIENT APPLICATION FORM
This form not to be used for application in Arizona, California, Colorado, Hawaii, Kansas, Kentucky, Minnesota, Montana, North Dakota, Wisconsin and Wyoming (review screening instructions).
May be used for all family members.
(Limit 4 Members per Household per Year).
A CONTACT PRESCRIPTION CANNOT BE OBTAINED THROUGH VISION USA.
If you prefer to email, fax or mail your application, click here to download the Vision USA Patient Application Form PDF (Spanish Version). 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 families. Services are donated by volunteer optometrists who are members of the American Optometric Association and may be limited in some areas.
COMPLETE APPLICATION FORM ONLY IF:
- The person seeking care has no private or government insurance, including Medicare or Medicaid
- 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; (see income level below)
- The person seeking care is a U.S. Citizen of Legal resident; and
- The person seeking care has not received a doctor referral through the VISION USA program in the last 2 years.
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. Income verification is required.
“Click Here” to apply online.
Please allow 3-5 weeks for determination of eligibility for the VISION USA program.