Fill out application below and schedule appointment with referral agency 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section 1, Applicant Information. Ensure all fields are completed, including your name, contact information, and social security number.
3. Proceed to Section 2, Income Worksheet. Accurately list all sources of income for each household member. This includes employment, child support, and any other relevant income.
4. In Section 3, answer whether you have received a doctor referral through the VISION USA program in the past two years. This is crucial for eligibility.
5. Finally, review Section 4 for the signature requirement. Confirm that all information is true before signing and dating the application.

Start using our platform today to fill out your application easily and schedule your appointment!