ࡱ> #` bjbjmm ;+qZPPPP8;8;8;8p;D;P<<4===W>W>W>.O0O0O0O0O0O0O$PhaSTOiA5>"W>AATOPP==%OEEEAP8==.OEA.OEEHLH=< `o8;OB<HILO0P H,UTCUTLHLH&UTrHpW>K?E?@6W>W>W>TOTO'E^W>W>W>PAAAA58;8;PPPPPP  UNIVERSITY EYE INSTITUTE EYE CARE ASSISTANCE PROGRAM The University Eye Institute - Eye Care Assistance Program (UEI-EyeCAP) was established to assist individuals in need of eye care. Whether you are eligible for the program and / or the level of assistance for which you may qualify, depends on your income, where you live, other help you receive or could receive, and the number of household dependents. Under the Eye-CAP guidelines, the professional staff at the University Eye Institute donates a portion, or in some cases, all of their time and services. Thus office visits, specialized testing, and out-patient surgeries are provided as a professional courtesy, according to the percentage or level of assistance for which you qualify. Applicants should be aware that there are restrictions as to the services, procedures, and / or materials that may be provided. For example, the EyeCAP does not apply to laboratory tests or certain procedures such as OPTOS mapping, nor does it cover hospitalizations, testing, or surgery performed outside the UEI. Certain patients, such as those seen in the NOVA clinic, are not eligible for the EyeCAP program. Spectacles, if required, will be offered at a reduced cost and will consist of frames from a special selection. Lenses will be provided as single vision, bifocal, or trifocal and does not include extras such as tints, anti-reflective coatings, or progressive lenses. Patients who qualify for the EyeCAP are also eligible for contact lens examinations and fittings where applicable, but there is no reduction of costs on materials. Children undergoing a Developmental evaluation, not covered by their Medicaid plan, are required to have a parent or legal guardian complete a similar application prior to the appointment and will pay a reduced fee prior to the examination. WHO QUALIFIES To qualify for the UEI-EyeCAP, several conditions must be met: The person must be a resident of Texas. A person is considered a Texas resident if the persons primary home or fixed place of habitation to which the patient intends to return after a temporary absence is located in the State of Texas. You do not have to be a U.S. citizen to qualify for financial assistance. However, if you are not a citizen, and you have documentation from the INS, it must be presented to determine your eligibility for assistance. A valid Texas drivers license will also be accepted. The applicant does not have medical insurance and cannot afford medical healthcare. When indicated, the patient must have applied and can document that they have been rejected for Medicare / Medicaid services. If you have Medicare coverage and you want to apply for financial assistance for fees and / or services not covered by Medicare, you must provide proof of your resources and liabilities. Medicare deductibles will be processed in compliance with Federal guidelines. Patients applying for the Eye-CAP must provide proof of their gross income (both earned and unearned) for the past 30 days, for all adult members of the household. Earned income is any income related to employment. Unearned income is income received without performing work (i.e. child support payments, disability insurance benefits, pensions, social security benefits, unemployment compensation, and / or workers compensation) and includes benefits from government- sponsored programs. The gross family income for the prior 30 days will be used as the basis for determining the patients level of financial assistance. Income from all adult members of the household must be included, even if all family members do not apply for financial assistance. Financial classifications will be based on the most current Federal Poverty Guidelines. Patients applying for financial assistance are required to declare and provide verification to identify all family members living in the household. Household income is the basis for determining what income is used when calculating the level of financial assistance. Household members will be defined as a group of two or more persons related by birth, marriage, or adoption who live together; all related persons (children and adults) are considered as members of one family. With regards to unrelated individuals living in a single household, the poverty guidelines will be applied separately to each family and/or unrelated individual within a household. Upon a six (6) month renewal, the applicant must provide verification of any change in the composition of the household (e.g. school enrollment documents, birth certificates, most recent IRS 1040 form with names of dependents). A renewal notice will not be sent to previous participants of the EyeCAP; however, a current application must be on file to receive the reduced fees. HOW TO APPLY (Applicants must apply in person at the University Eye Institute) If you meet the above criteria, please complete the UEI-EyeCAP application form and return it with at least one (1) of the documents requested for each category. If you do not answer all the questions on your application, the UEI will not be able to determine if you are eligible for financial assistance. If you are qualified for financial assistance and it is later determined that the information or proof you provided was false, you may lose your EyeCAP eligibility and be required to repay the UEI for any services rendered. You may also be charged with criminal and / or civil penalties. Identification for each adult: Texas drivers license with picture Texas identification card with picture U.S. immigration documents with picture School ID with picture Federal documents showing identity and residency in Texas (Citizenship, IRS 1040 or other related tax forms) Childrens identification Birth certificate for each child who lives Proof of school enrollment with you: Hospital or birth records Adoption papers or records Income verification: Paycheck stubs for one months salary Wage verification letter Current year 1040 tax form Retirement checks or statements Temporary Assistance for Needy Families (TANF) award letter Medicaid / Medicare / SS certification documents Unemployment documentation Section 8 housing award letter Proof of Current Address: Lease agreement Voter registration (current) Tax return (current) Utility bill School records for minor children Mortgage coupon Property tax statement Certification documents from Food Stamps, Medicare, or Medicaid Letter from shelter confirming current residence NOTE: If you are unemployed and living with family members, please provide proof of household income and number of household members for the family with whom you are living. Seasonal workers should provide gross income for the past 12 months. Income proof, such as a tax return or check stubs must be provided, but may be up to 12 months old. Self-employed patients must provide proof of self-employment income. You must report within 14 days any changes in your address, income, people living with you, or receipt of any other financial assistance (i.e. Medicaid). Failure to report these changes may result in losing your assistance from the UEI. If you are accepted into the assistance program, please note that payment will be expected the day services are received. If payment cannot be made, fee reductions will not be applied and your appointment can be re-scheduled. Name: ___________________________________________________ Signature: _________________________________________________ Date application received: _____________________________________ Date application approved: _____________________________________ UNIVERSITY EYE INSTITUTE EYE-CARE ASSISTANCE APPLICATION Applicants Name (Last, First, Middle): Social Security #:Home Telephone No.Work Telephone No. Cell Phone No.  Home Address: Apt #CityStateZIPCounty Have you ever gone by another name? List other names you have used: % Yes % No Reason you are asking for assistance: How did you meet your expenses until now? 1. Fill in line (a) about yourself. Fill in the remaining blanks for everyone who lives with you. NAME (Last, First, Middle) WHAT RELATION-SHIP TO YOU?DATE OF BIRTHS E X RACE U.S. CITIZEN Y / NLEGAL ALIEN Y / N IN SCHOOL Y / NSOCIAL SECURITY NUMBER Applicant (a) SELF(b) (c) (d) (e) (f) (g)  2. List all of your households income: NAME OF PERSON WORKING OR RECEIVING MONEYNAME OF EMPLOYER, PERSON, OR AGENCY THAT PROVIDES THE MONEYHOW OFTEN RECEIVED?AMOUNT RECEIVEDIF SOCIAL SECURITY, ENTER CLAIM NO.    TOTAL INCOME $  3. Have you or has anyone living with you worked in the past three months? %Yes %No 4. Living arrangements: Check all boxes that apply to your household: % Own or Paying for Home % No Permanent Residence % Renting % Migrant or Seasonal Farm-worker % Live with Relatives or Friends 5. Please list the amount of your monthly expenses: Rent/Mortgage$ Electricity$ Telephone$ Food$ Car$ Child Support (if applicable)$ Tax on home$ Insurance on Home$ Does anyone else pay these expenses for you? % Yes % No 6. Do you have additional sources of income, such as child support, food stamps, social security, disability, or Section 8 Housing? If yes, please describe: 7. Do you have health insurance/Medicare/Medicaid? %Yes %No Type (HMO, PPO, Medicare (A or B), Medicaid, etc.)? Medicaid Identification number Does anyone in your household have health insurance/Medicare/Medicaid? %Yes %No Type (HMO, PPO, Medicare (A or B), Medicaid, etc.)? Medicaid Identification number Have you or anyone in your household applied for Medicare/Medicaid? %Yes %No 68TVW! 7  \ ] m W b ~ C[s68@PQRjlZҼҰҰҼҢҢʢʢʢʼʼҎh$8h[]>*CJaJhuh[]5h?oh[]56CJaJhm(.h[]5CJaJh$8h[]56CJaJh[]CJaJh0U,h[]CJaJh0U,h[]5CJaJhqyRh[]5 h[]5hT5CJaJ8678 DE678QR$ & F0]0a$gd[]$0@ ]0^@ a$gd[]0]0^`gd[] $0]0a$gd[] $0]0a$gd[] $0]0a$gdaX{vX stu`]^234h 0]0`gd[]$0h]0^ha$gd[]$0]0^a$gd[]$ & F0]0a$gd[] $0]0a$gd[]st`h\^zC234mox "+egh{} ѽߎh3Jh[]5CJaJhy1h[]56>*CJaJh0U,h[]5CJaJhqyRh[]5h[]5CJaJh[]56CJaJhy1h[]56CJaJh[]CJaJh$8h[]56CJaJh0U,h[]CJaJ8(? Gcefgh6 $0\ ]0^\ `a$gd[]$0T]0^T`a$gd[]$0\ ]0^\ a$gd[] $0]0a$gd[]  ! 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Give your household s county and state of residence (where you make your permanent home): County: State: 9. Do all the listed people who want assistance plan to stay in this county and state as residents? % Yes % No 10. If you are unemployed, complete the information below: I, (your name), am unemployed. My income per month is $ which is from (source of income). Additional monthly income for my immediate family comes from (source) and totals $ per month. I (we) have no other source of income, including savings, real property, or rental property. 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