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Assistance Request Form

Applicable Services/Materials

Routine eye exams, medical or specialty visits, and/or glasses/contact lenses up to $500/year. Payment will be issued directly to the practice providing services/materials.
 

Requests for coverage exceeding $500 will require board review and approval. 

Eligibility

  • Uninsured/Under-insured

  • Referral from a partner agency 

    • Referral not required for approval

  • Household income at or below 250% of federal poverty line

Please fill out the following form to the best of your ability to request assisance

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