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1. Patient Demographic Information
Please complete the application in its entirety, providing as much information as possible. Failure to do so may result in delay of your application being reviewed or considered for candidacy.
Gender
Gender (*)
Female
Male
Marital Status
Marital Status
Single
Married
Divorced
Widow/er
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Interpreter Needed?
Interpreter Needed?
Yes
No
** Below immigration status given is private. We use it only to help us determine if you may be eligible for any other assistance programs available. It’s also used to determine if the patient will be in the U.S. for appropriate pre and post operative time frames.
Does the Patient Have a Sponsor?
Yes
No
2. Contact Information (Skip if same as above)
Please list an English speaking contact person if possible.
3. Eye Care Services or Procedure(s) Requested
Procedure(s) Recommended. Ask your doctor if you do not know this information. (*)
Which Eye (*)
Which Eye?
Right
Left
Both
Please Send Most recent Visit Summary/Notes to our Medical Records Fax #952-567-6156.
4. Patient Employment Status (*)
Employment Status
Employed
Self Employed
Seasonally Employed
Not Employed
Wages (including tips)
Frequency of Wages/tips
Hourly
Weekly
Bi-weekly
Monthly
Average Hours Worked Per Week
5. Patient Insurance Status
Does The Patient Have Insurance? (*)
Does The Patient Have Insurance?
Yes
No
If No, Have They Applied For State Medical Assistance?
Yes
No
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6. Household Information
Please list ALL members residing in the same household other than the patient. This may be a spouse, children, parents, other dependents, family members, roommates, etc. Please also include income and employment information for ALL members of the household. Complete household information is a requirement for overall qualification.
HOUSING STATUS
Own
Rent
Staying with Someone
Other
How many people live in your home?
Default
0
1
2
3
4
5
Household Member Name(1)
Employment Status
Employed
Not employed
Minor or child
Frequency of Wages/tips
Hourly
Weekly
Bi-weekly
Monthly
Other Income
Unemployment :
Pension/Retirement :
Social Security:
Child or Spousal Support :
Supp. Security Income (SSI) :
Other :
Other :
Household Member Name(2)
Employment Status
Employed
Not employed
Minor or child
Frequency of Wages/tips
Hourly
Weekly
Bi-weekly
Monthly
Other Income
Unemployment :
Pension/Retirement :
Social Security :
Child or Spousal Support :
Supp. Security Income (SSI) :
Other :
Other:
Household Member Name(3)
Employment Status
Employed
Not employed
Minor or child
Frequency of Wages/tips
Hourly
Weekly
Bi-weekly
Monthly
Other Income
Unemployment :
Pension/Retirement :
Social Security :
Child or Spousal Support :
Supp. Security Income (SSI):
Other :
Other:
Household Member Name(4)
Employment Status
Employed
Not employed
Minor or child
Frequency of Wages/tips
Hourly
Weekly
Bi-weekly
Monthly
Other Income
Unemployment :
Pension/Retirement :
Social Security :
Child or Spousal Support :
Supp. Security Income (SSI) :
Other :
Other:
Household Member Name(5)
Employment Status
Employed
Not employed
Minor or child
Frequency of Wages/tips
Hourly
Weekly
Bi-weekly
Monthly
Other Income
Unemployment :
Pension/Retirement :
Social Security :
Child or Spousal Support :
Supp. Security Income (SSI) :
Other :
Other:
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7. Household Monthly Bills/Obligations
Please list all monthly bills or other financial obligations for the complete household. If a particular bill/obligation does not apply to you, please enter $0. The below list may not be all inclusive for each applicant, so please add any items that apply to you that are not listed below.
TYPE OF BILL/OBLIGATION
MONTHLY $ AMOUNT
IS PATIENT DIRECTLY RESPONSIBLE FOR ONLY A PARTIAL PAYMENT?
MORTGAGE/RENT
MORTGAGE/RENT
MORTGAGE/RENT is partial?
Yes
No
if partial
UTILITY - GAS
UTILITY - GAS
UTILITY - GAS is partial?
Yes
No
if partial
UTILITY - ELECTRIC
UTILITY - ELECTRIC
UTILITY - ELECTRIC is partial?
Yes
No
if partial
UTILITY – GARBAGE
UTILITY – GARBAGE
UTILITY – GARBAGE is partial?
Yes
No
if partial
UTILITY – WATER/SEWER
UTILITY - WATER/SEWER
UTILIY - WATER/SEWER is partial?
Yes
No
if partial
PHONE – CELL/OTHER
PHONE – CELL/OTHER
PHONE – CELL/OTHER is partial?
Yes
No
if partial
CABLE / INTERNET
CABLE / INTERNET
CABLE / INTERNET is partial?
Yes
No
if partial
CAR PAYMENT
CAR PAYMENT
CAR PAYMENT is partial?
Yes
No
if partial
CAR INSURANCE
CAR INSURANCE
CAR INSURANCE is partial?
Yes
No
if partial
MEDICAL BILLS – PATIENT
MEDICAL BILLS – PATIENT
MEDICAL BILLS – PATIENT is partial?
Yes
No
if partial
MEDICAL BILLS – OTHER MEMBERS
MEDICAL BILLS – OTHER MEMBERS
MEDICAL BILLS – OTHER MEMBERS is partial?
Yes
No
if partial
MEDICATIONS - PATIENT
MEDICATIONS - PATIENT
MEDICATIONS - PATIENT is partial?
Yes
No
if partial
MEDICATIONS – OTHER MEMBERS
MEDICATIONS – OTHER MEMBERS
MEDICATIONS – OTHER MEMBERS is partial?
Yes
No
if partial
CREDIT CARD DEBT - TOTAL BALANCE
CREDIT CARD DEBT - TOTAL BALANCE
CREDIT CARD DEBT - TOTAL BALANCE is partial?
Yes
No
if partial
CREDIT CARD DEBT - MONTHLY PAYMENT
CREDIT CARD DEBT - MONTHLY PAYMENT
CREDIT CARD DEBT - MONTHLY PAYMENT is partial?
Yes
No
if partial
GROCERIES/FOOD
GROCERIES/FOOD
GROCERIES/FOOD is partial?
Yes
No
if partial
OTHER
OTHER - 1
OTHER-1 is partial?
Yes
No
if partial
OTHER
OTHER - 2
OTHER - 2 is partial?
Yes
No
if partial
OTHER
OTHER - 3
OTHER - 3 is partial?
Yes
No
if partial
OTHER
OTHER - 4
OTHER -4 is partial ?
Yes
No
if partial
8. PLEASE PROVIDE A SUMMARY OF WHY YOU FEEL YOU SHOULD BE CONSIDERED A CANDIDATE FOR FREE EYE CARE SERVICES WITH OPERATION EYESIGHT. PLEASE INCLUDE MORE INFORMATION ABOUT THE PATIENT: THEIR INTERESTS, DAILY ACTIVITIES, CHALLENGES DUE TO EYE ISSUE, AND ANY OTHER EXTENUATING CIRCUMSTANCES IMPACTING THE PATIENT. (*)
9. PLEASE PROVIDE A SUMMARY OF WHY YOU FEEL YOU SHOULD BE CONSIDERED A CANDIDATE FOR FREE EYE CARE SERVICES WITH OPERATION EYESIGHT. PLEASE INCLUDE MORE INFORMATION ABOUT THE PATIENT: THEIR INTERESTS, DAILY ACTIVITIES, CHALLENGES DUE TO EYE ISSUE, AND ANY OTHER EXTENUATING CIRCUMSTANCES IMPACTING THE PATIENT.
I declare that all parts of this application are true and correct statements, to the best of my knowledge. I understand that the details of this application are solely used to determine my overall financial status and possible eligibility for Operation Eyesight.
Patient Signature (*) :
Clear
To sign electronically above, please click and hold your cursor to sign your name.
SUBMIT