The Wisconsin Project Patient Application Form printable pdf download

VISION USA – The Wisconsin Project

Patient Application Form

VISION USA – The Wisconsin Project is an independent program run by the Wisconsin Optometric Association (WOA), a

non-profit association consisting of doctors of optometry that practice in Wisconsin. The program offers comprehensive

eye care services to children age 18 and under who are from low income, working families and have no insurance which

covers vision and eye health care. Applications will be accepted year-round, and if approved, the applicant will be sent

information in order to contact a local doctor to set up an eye exam. It is the parent/guardian’s responsibility to contact the

doctor and make the appointment. Each eligible child will receive a free comprehensive eye examination. Note: WOA

volunteer doctors provide these services, and a participating doctor may or may not be available in your area.

Eligibility requirements are as follows. Please read them carefully, to make sure your child qualifies:

1. Patients must be age 18 or under and enrolled in K-12 school in Wisconsin.

2. Patients must have NO insurance which covers eye care (this includes vision and eye health coverage

through Medicaid, Blue Cross/Blue Shield, and BadgerCare). If the patient has insurance that covers eye

care, he or she will be denied an exam through VISION USA – The Wisconsin Project.

3. Patients must NOT have had an eye exam provided by an eye doctor within the last 12 months of applying for

the program. If the patient has had an eye exam by an eye doctor within the 12 months of application,

he or she will be denied an exam through VISION USA – The Wisconsin Project.

4. Family income must be within an established level according to household size; this is based upon the U.S.

Federal Poverty Guidelines. **Parents or guardians must enclose either a copy of their most recent tax

return, or a verification letter from the child’s school stating that the child qualifies for free/reduced

lunch. If proper income verification is not included with the application, the application will be

returned to the parent/guardian.

5. Parent or guardian of the child must be currently working at least part-time.

The applicant must meet ALL requirements to qualify for the program.

More than one person in each family may apply for a VISION USA exam, if eligibility requirements are met. Please submit

one application per child. For more information or to obtain an application in Spanish, please visit the VISION USA

page on the WOA website, , or call 1-877-435-2020. Please note: WOA staff

does not speak Spanish.

Send this completed form, with requested information, to the WOA office at the following address:

VISION USA – The Wisconsin Project

6510 Grand Teton Plaza, Suite 312

Madison, WI 53719

Fax: 608-824-2205

The Wisconsin Project Patient Application Form