Get Healthy Eyes Eyeglass Program Client - Prevent Blindness Texas - Texas Preventblindness

The Healthy Eyes Eyeglass Program offers assistance to individuals in need of eyeglasses. This guide will help you navigate the process of completing the application form, ensuring that you provide all necessary information to qualify for the program.

Follow the steps to successfully complete your application form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out Section I, which includes client general information. Provide your first name, last name, date of birth, age, race, sex, mailing address, city, state, zip code, phone number, email address, and county. Ensure all information is clear and legible.
3. Proceed to Section II, where you will answer questions regarding your eligibility and background information. Carefully respond to each question about your vision screening, enrollment in Medicare or Medicaid, receipt of veterans benefits, current prescriptions, previous support from the OneSight program, yearly household income, and total household members.
4. In Section III, read the client agreement carefully. This section outlines the confidentiality of your information and the restrictions related to the program. It is important to understand these terms before signing.
5. Once you have reviewed the entire application and confirmed that all information is accurate, add your signature and date at the bottom of the form. If you are completing the form on behalf of a minor, provide your signature as the parent or guardian.
6. Finally, submit the completed application via mail or fax to the provided contact information: 2202 Waugh Dr., Houston, TX 77006, or fax to 713-529-8310. Keep a copy of the application for your records.

Complete your Healthy Eyes Eyeglass Program application online today to take the first step towards obtaining your eyeglasses.