Adult Vision Voucher Application

Please Note: If you are applying for an eye exam/glasses only voucher, you will not qualify if you have vision insurance (including Badgercare).

If you are applying for the glasses only voucher you may still qualify if you have vision insurance. You will have had to exhausted your vision coverage limit for the year.

Qualification criteria can be found here. For additional questions or concerns, please contact [email protected].

Online Adult Vision Voucher Application

Pre-Screening Form

MM/DD/YYYY
Are client questions before the vision screening starts:

Are client questions before vision screening starts (children's vision health questions):


Are client questions before the vision screening starts:




Risk Assessment

Risk Assessment

Application


I attest that the above information is true to the best of my knowledge. I understand that if I provide incomplete or incorrect information I may be required to pay for the vision care services I receive and I may be declined service. 
To be completed by agency staff if applying through an agency

Contact Information