Adult Vision Voucher Application

Applicant Information:

I am applying for:

Glasses Only

Eye Exam & Glasses

First Name

Last Name

Date of Birth:

Phone

Alternative Phone

Email

Address Line 1

City

Postal Code

State

Country

County

Vision Health Information

Have you had an eye exam in the last 12 months?

YesNo

Date of last eye exam:

Have you used a vision care voucher in the last 12 months?

YesNo

Please indicate the type of voucher used

VSP Mobile EyesHealthy EyesOther

Other vision voucher

Financial and Insurance Information

Please provide at least ONE proof of income document: pay stub, tax return, Social Security Award Letter etc.

Annual Household Income:

Number of people in household including yourself:

Do you have Medicaid, VA Health Care or other vision insurance?

YesNo

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.

Signature:

Date:

To be completed by agency staff if applying through an agency.

Agency ID

Agency Contact ID

Agency Contact:

Address Line 1:

City:

Postal Code:

Send Voucher Information to:

Send Voucher approval letter in: