Vision Assistance Form
The purpose of the Vision Assistance Program is to help individuals within the Texas Lions District 2-E2 who are in the country legally with a one time monetary assistance to provide vision care that cannot be funded by regular means.
Vision Assistance Application Forms
To request Vision Assistance from the Lions Club District 2-E2 Organ and Eye Bank – please download the Vision Assistance Form pdf and follow the instructions below to complete and submit the form.
Lions Club District 2-E2 Organ and Eye Bank – Vision Assistance Form English
Lions Club District 2-E2 Organ and Eye Bank – Vision Assistance Form Spanish
Lions Club District 2-E2 Organ and Eye Bank – HIPAA Release Form
Vision Assistance Form – Application Instructions
Thank you for allowing the District 2E2 Lions Organ and Eye Bank to review your application for possible vision assistance. You will need to be sponsored by a 2E2 Lions Club in order for your application to be considered.
Please completely fill out the application and supply these supporting documents:
• Copy of previous year’s income information
• Last 2 paycheck stubs for each working member of household
• Copies of any forms of assistance. such as food stamps award letter, 551 or disability and/or housing assistance, unemployment, etc.
• Copies of all insurance cards
• Proof of residency (electric bill, lease agreement, etc.)
• Copy of picture ID
• Copies of any medical records pertaining to condition you are requesting treatment for, along with a brief description of services requested from the person who will be providing the service
• Authorization to Disclose Protected Health Information – the HIPAA form must be completed and signed. This is necessary so we can discuss your application and obtain more information from your physician if necessary.
• We are a non-profit organization with limited funding. Our help to you may be to connect you to services at another organization.
• Non-emergency situations may require a partial payment by the applicant (or a third party) to the treating doctors prior to service.
• We do not pay for prior services, except in extraordinary circumstances.
• No requests for non-FDA approved or experimental treatments will be considered.
• We will consider elective treatments on a case by case basis, and we have the right to deny funding for any lawful reason.
• Each case will be considered on an individual basis.
• We provide help with medically necessary treatments only. We may discuss the provisions of our assistance with your doctor’s office and this might affect your treatment plan.
• We will give careful consideration to your application. Please complete the application and send all supporting documents requested.
• At this time we are unable to assist those who do not have a Social Security number and/or are in this country illegally.
• Your application will be considered after all information has been received. This process usually takes 3-6 weeks.
• The application will not be considered if you are not sponsored by a District 2E2 Lions Club.
The Lions Organ & Eye Bank of District 2E2, Inc., is a 501 (c)3 organization.