Vision Outreach Voucher & Clinic Application

Please read this completely before filling out the form.

Prevent Blindness Georgia administers various second party vision care assistance programs. Those organizations have set eligibility requirements which must be strictly adhered to in order to ensure that individuals are truly in need of the benefits from the programs.  

Please note that vouchers are not always available in every county.  Prevent Blindness Georgia may offer vision exams and access to glasses at our community-based vision clinics for certain counties.    

Please note that due to the charitable nature of this program, we assist those that do not have access to vision care at all. If you have a co-pay or a spend down that is required with your vision coverage, you may be ineligible for this program.  

 If you do not have vision care coverage, please complete this application so that we may determine which of the programs you (or your child) may be qualified for. Please read this application in its entirety. Please attach copies of all requested documents so as not to delay processing. Originals cannot be returned.

You will be notified of your eligibility via email or telephone within 4 weeks of receipt of your application.  

You will need:

TWO (2)  proofs of income – they are REQUIRED. Applications WILL NOT be processed without TWO (2) proofs of income. Proof of income or a NOTARIZED document may come from you or someone that may provide financial assistance to you, explaining their assistance. It may also come from an organization (on their letterhead) that is referring you if you have no income. Please note that all applications sent WITHOUT appropriate income verification will not be processed.

Proof of income includes: 

  • Last year’s W2
  • Last 2 months of bank statements = 1 proof of income
  • 2 current paycheck stubs = 1 proof of income
  • Social Security Administration Award Letter.
  • Unemployment Claim/Wage Inquiry statement
  • ANY information regarding financial circumstances, including monthly amounts received on ANY other sources of income (ex: TANF, pension, retirement, child support, food stamps, part time employment, etc.)

If you are having any issues with the form, please email [email protected] or [email protected]

Form Below:

VO Voucher & Clinic Application

Prevent Blindness Georgia administers various second party vision care assistance programs. This form is for individuals who do not have access to vision care at all due to not having vision insurance.

Services needed(Required)
Please select which best reflects your needs
Please select which type of insurance you have:

please include ALL household income, spouse's income, dependent income, etc.
Max. file size: 10 MB.
Max. file size: 10 MB.
By typing your name here, you are attesting that the above information is true to the best of your knowledge.
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