Rx Goggles Parent Application Form

Prescription Goggles Patient Application Form

Qualification

Welcome to the PHDB free Prescription Sports Eyewear Safety Goggle Program. This program is sponsored by Save Our Sight, Ohio Prevent Blindness and the Ohio Ophthalmological Society with an Ohio Department of Health grant for children at or below 300% of the Federal Poverty Guidelines. (For 2017-2018 - Family of 4, the maximum gross annual income is $73,800).
As of March 11, 2016, the program changed to an ALL online, paperless program. Previously mailed paper vouchers will still be valid as long as we have funding in our program, but with the new application process, vouchers are no longer needed. Parents with the old vouchers, do NOT have to complete the new PARENT APPLICATION FORM this time. Once parents have a voucher or application approved, they can proceed to the nearest Participating Office to place a goggle order. (CLICK ON THE PARTICIPATING OFFICES LINK BELOW TO LOCATE)

ALL PARENTS: - BEFORE YOU COMPLETE THE ONLINE APPLICATION, YOU MUST READ THESE INSTRUCTIONS...

Please complete the application below carefully. You will know you are approved when you get to the end, click submit and you IMMEDIATELY receive an email stating you are approved.. A confirmation email will be sent to the email address you provided. Since it is computer generated: Check your SPAM, JUNK MAIL AND CLUTTER folders for this REPLY email.

After your approval email, you are ready to choose a Participating Office from the link provided below. You do not need to take anything with you besides your child and their prescription. The Participating Office will order the Prescription Sports Goggles, and they will be delivered within 6 weeks to your home address. This is the only timeline you will be given. We do not monitor the day to day status of the orders. Please be patient.

If your application will not submit, this means you have not been approved and we thank you for your interest.

REMEMBER: After you are approved, contact a Participating Office from the link below, then take your child and child’s prescription (offices have access to our database to verify your approval) and they will fill out the Order Form. In special circumstances, if you are homebound or unable to find a nearby office, you may gather ALL the information and complete the order yourself. We DO NOT recommend this as the process is highly technical. We do not provide exchanges/returns for incorrect orders AND you must wait 12 months before applying again.

EXCEPTIONS for income guidelines:
1. If you are a foster parent, child is automatically approved, choose FOSTER where it asks for the number of people in your household.
2. If your child has a permanent eye injury or debilitating optical disease that is being treated by an Ophthalmologist - please email us a letter at oos@ohioeye.org signed by their treating physician, stating disease, condition and contact information. We will review these applications on a case by case basis.

ALL ORDERS WILL BE SHIPPED TO PATIENT'S HOME WITHIN 6 WEEKS. NO RUSH ORDERS. We can be contacted with questions at oos@ohioeye.org. No phone calls please. Thank you for your interest.


PLEASE!!! DO NOT COMPLETE THIS APPLICATION WITHOUT READING INSTRUCTIONS GIVEN BETWEEN THIS LINE AND THE TOP OF THE FORM. ---ALL YOUR QUESTIONS CAN BE ANSWERED ABOVE---

Click here for a LIST OF PARTICIPATING OFFICES

INCOME QUALIFICATIONS - TOTAL GROSS INCOME CANNOT EXCEED THIS AMOUNT - PLEASE REVIEW THIS CAREFULLY!

Number of People in Household
Household Income
2
$48,720
3
$61,260
4
$73,800
5
$86,340
6
$98,880
7
$111,420
8
$123,960
9
$136,500
10
$149,040

Child's Information

Please enter the name and age for the child you wish to apply for. Each child will need their own application form submitted.
Your child must be between the age of 4-18 in order to qualify
Please do not include any symbols and round to nearest whole dollar (ex: 30000)

Parent/Guardian Contact Information

PLEASE --- DO NOT PROCEED UNTIL YOU HAVE READ ALL THE INSTRUCTIONS AT THE TOP OF THIS PAGE. THE ENTIRE PROCESS IS GIVEN IN DETAIL.
Goggles will be mailed directly to your residence within 6 weeks. No rush orders.
Only Ohio residents are eligible at this time.
DO NOT PROCEED UNTIL YOU HAVE READ ALL THE INSTRUCTIONS AT THE TOP OF THIS PAGE.
Play Hard. Don't Blink is funded by a grant awarded by the Ohio Department of Health, Bureau of Maternal and Child Health Save Our Sight Fund. For more information about the Save Our Sight Fund and how you can help promote good eye health and safety for children in Ohio, visit: www.saveoursight.ohio.gov.
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