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Application for Free Eye Surgery

Information is confidential and protected by HIPAA.

The Vision of Justice free surgery program is for indigent individuals only. All information provided is confidential. A background check will be performed to verify indigent status.

Patient Information

*Name of Patient (Person needing surgery):

*Patient’s Phone:

*Patient’s Full Address:

*Patient’s Email Address:

*Patient’s Age:

Contact Person (if different from patient)

Name of Contact Person:

Contact Person’s Phone:

Contact Person’s Email Address:

Financial Information

Patient’s Income Per Year: $

List all income sources, including public assistance, disability, social security, etc.:

from:

Income source 2

from:

Income source 3

from:

Income source 4

from:

More Information

Medical Information

Patient’s Current Diagnosis/Condition:

Is the Patient Legally Blind?

Yes
No

Name of Patient’s Eye Doctor/Medical Provider:

Provider’s Address:

Provider’s Phone:

Medical Eligibility Questions

1. Have you been diagnosed with visually significant cataracts?

Yes
No

2. Do you have any other eye conditions that may interfere with cataract surgery?

Yes, list all here:
No

3. Do you have a MEDICAL condition that may interfere or prevent you from cataract surgery?

Yes, I have:
No

4. Are you able to come to our office for a full evaluation to determine if cataract surgery is warranted?

Yes
No

5. Do you have a medical doctor who can check and clear you for surgery?

Yes, they are:
No

6. Do you have someone to transport you to and from our surgery center?

Yes, it is:
No

7. Do you have family who can assist you with instilling eye drops after surgery?

Yes, it is:
No

Medical Insurance

Do you have ANY KIND of medical insurance?

Yes
No

Medicaid

Policy Number:

Group Number:

Plan Type:

Medicare

Policy Number:

Group Number:

Plan Type:

Veterans Affairs

Policy Number:

Group Number:

Plan Type:

Other:

Provider Name:

Policy Number:

Group Number:

Plan Type:

Applications Are Currently Closed

Applications are currently closed, and we are not accepting new submissions at this time. We do not have a confirmed timeline for reopening at this time, but we will share updates should circumstances allow us to resume accepting applications.

If you have questions, please call (248) 707-1322.

August 2026

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call_black_24dp 22 (248) 707-1322

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