Prevent Blindness Certificates Eligibility & Application

This is the application to request assistance for either an eye exam and/or help with getting a pair of prescription glasses that our program can assist in requesting through a partnership with Prevent Blindness (PB). 

Application PDF
 
If approved, the gift certificate would provide an exam and/or glasses through a local participating Vision Service Provider.  
 
Who’s Eligible?
    • Family income at or under 200% of Federal Poverty Level guidelines.
    • No coverage through a private insurer or government program for services covered by the gift certificate.
    • Haven't received care through a VSP program during the last 12 months.

Please also see additional details, including limits and list of local providers who accept the certificate, here.

Please email the completed application to caseyoutreach@ohsu.edu, and the applicant will be notified if their application was approved in 4-5 weeks.