Multiple District 44 Constitution & By-Laws Approved January 27, 2007
 

Lions Sight & Hearing Foundation of NH, Inc.
 

Lions Eye Clinic
 

New Hampshire Blind Bowlers
 

MD 44 NH Lions Health Services Board

Process for using Eye Clinics

1. Have prospective client(s) complete MD 44 HSB Application for Eye Care. 
This application must be used in order to utilize the MD Eye Clinics.  

2. Review all information on form; be sure to verify whether client(s) has
any insurance coverage for eye care.  See Information List. 

3. After determination that client has no other means of coverage and is
within standard guidelines, set by your club, mail or fax a copy of the
application to the eye clinic scheduler.  Joanne Pouliot,

266 E. Dunbarton Rd, Goffstown, NH  03045.  Fax:  497-8028

4. Upon receipt and review of application the eye clinic scheduler will
contact the club person whose name appears on the bottom of page 2
of the application.  A date, time and location will be given to the club
contact who in turn will notify their client.

5. Be sure to inform you clients that the doctors are volunteering their
time to do these exams and missing an appointment will not only mess
up the schedule but also denies others of an opportunity to be there. 
Also ask them to arrive about 10 minutes early to fill out a health care
form and be sure to send the written form telling the clinic staff where
your client should be referred to for glasses.

See Procedures for use of Lions Eye Clinics for more details on each step.

Always use the application process even if clients are referred by trusted contacts. 
Many people have been sent to the clinics for an exam when in fact they have
coverage and no one at the club level asked them about it.

Remember—the clinics were started to help people that don’t have coverage!

Different coverage’s:

School age children have a program through Medicaid called Healthy Kids-Gold.  
Many children in the state are enrolled in this program, which provides their
necessary eye care each year.   They can use the same providers as other Medicaid recipients.  Most teachers we have dealt with are not asking if the children are in the Healthy Kids program before they refer them to us.  Please be sure to check on this
possibility.  These people should not be coming through the Lions Eye Clinics or
having our clubs pay for their glasses. 

People 65 or older have Medicare coverage.  This program will cover the cost of
an eye exam once every two years if but not the cost of glasses.  Have these
people see the doctor of their choice for their exam, which will be taken care of
by Medicare, and then once they have their prescription the club can finance
the glasses through Lens Crafters for $50.00.  Keep in mind that Medicare will
only pay for a pair of glasses after cataract surgery so tell you client that it is
best to have both eyes done one after the other in order to best benefit from
this.  That is, of course, if both eyes have cataracts.

People with Medicaid have coverage.  This program will cover an exam and
glasses every year.  These clients are also provided with any necessary
transportation to get to these appointments.  They should not be coming
through the Lions Eye Clinics or having our clubs pay for their glasses.  There
is a list available of Medicaid providers. 

MD 44 HEALTH SERVICES BOARD - -LIONS CLUBS

APPLICATION FOR EYECARE AID

IF YOU DO NOT SPEAK ENGLISH YOU MUST PROVIDE AN INTERPRETER!

All questions MUST be answered if this application is to be considered.  Information revealed herein will be kept strictly
confidential and will be used solely for the evaluation of you request for financial assistance.  NO professional treatment
will be paid for by the Lions Club unless expressly authorized in writing by our President or designated member.
 

1.  APPLICANT__________________________________________________________________

                                         First Name                                                 Middle Initial                              Last Name

    1A.  SOCIAL SECURITY NUMBER _______--______--________       Date of Birth_________________

2.  REFERRED BY:_____________________________________________ODAY’S DATE___________

3.  CURRENT ADDRESS____________________ _________________  _______     ____________

                                                                       Street                                                    City                           Zip Code            Number of years there

     PREVIOUS ADDRESS_____________________ _________________  ______      ___________

                                                                       Street                                                    City                           Zip Code            Number of years there

4.  INDICATE WHETHER APPLICANT IS ALREADY ELIGIBLE FOR EYE CARE AID FROM THE FOLLOWING SOURCES:

The Lions are able to help only those who have no one else to turn to for eye-care aid.  If you’re not sure of eligibility from
the following, please call them and ask.  If they indicate you’re not eligible, please indicate the reason below.

Yes/No

______  SCHOOL CHILDREN  from  kindergarten to graduate of 12 years---Healthy Kids Program or other source.

______  INCOME ASSISTANCE

______  PERMANENTLY DISABLED individuals*

______  SENIOR CITIZENS age 65 or older*  or having Medicare coverage/please list card number____________________

______  TANF recipients*

______  MEDICAID COVERAGE* please list card number____________________________

______  UNITED STATES VETERAN

*Eye-care is provided by Medicaid (if these individuals are financially needy) thru the
NH Division of Human Services

REASON:____________________________________________________________________________________________

5.  PHONE NUMBER WHERE YOU CAN BE REACHED___________________TIME TO CALL______________________

6.  EMPLOYER____________________________________________________OCCUPATION_______________________ 

    DATE HIRED_____________       NET INCOME_____________/MONTHLY           DATE LEFT____________________

6A.  PREVIOUS EMPLOYER_________________________________________OCCUPATION_______________________

    DATE HIRED_______________   NET INCOME_____________/MONTHLY       DATE LEFT_______________________    

7.  OTHER INCOME:                              DATE STARTED            DATE ENDED               AMOUNT / MONTHLY

     Pension                                           _____________ ___________                 __________________

     Investments                                      _____________ ___________                 __________________

     Social Security                                 _____________ ___________                 __________________

     Workmen’s Compensation                 ____________               ___________                 __________________

     Unemployment Compensation            _____________ ___________                 __________________

     NH Welfare                                        _____________            ___________                 __________________

     TANF (Temp. Aid for Needy Families)_____________  ___________                 __________________

     Other _____________________         _____________ ___________                 __________________

                                                                                                                        Total     __________________

8.  PLEASE COMPLETE THE FOLLOWING FOR ALL INDIVIDUALS LIVING WITH APPLICANT:

Name                                        Relationship                              Age                  Monthly Income

      ________________________             _________________                  ____                 _______________

      ________________________             _________________                  ____                 _______________

      ________________________             _________________                  ____                 _______________

      ________________________             _________________                  ____                 _______________

8.                      (CONTINUED)

 ________________________            _________________                 ____              _______________

­­­­­­­­­­­­­­­­­­­­­­­­­­ ________________________            _________________                 ____              _______________

9.  Child Support:______________(monthly)   Alimony:  ______________(monthly)   VA Disability:  ____________(monthly)

Total value of :  Checking and Savings accounts $__________________           Investments $_______________________

Car 1 _______         ________________________________    Amount of Loan Payment ____________________

            Year                                                         Make                                                                                                       Monthly

Car 2 _______         ________________________________    Amount of Loan Payment ____________________

            Year                                                         Make                                                                                                       Monthly

Real estate owned:  Description__________________________________Current value $________________

10.  HOUSEHOLD EXPENSES   YOU PAY:

          Apartment rent/Mortgage payment  _____________monthly     AND/OR   Amount paid by Section 8 pays_________

          Heat & Electric                               _____________monthly     Amount of fuel assistance received______________

          Food allowance received                ______________monthly    Recurring medical expenses    ___________monthly

List other expenses:  _________________________________________________________________

_______________________________________________________________________________

10A.  ARE YOU RECEIVING HEAT, HOUSING OR FOOD ASSISTANCE OF ANY KIND? ___ MONTHLY AMOUNT______

11.  HAVE YOU PREVIOUSLY APPLIED TO A LIONS CLUB FOR EYE-CARE AID? ____________YEAR? _____________

12.  WHAT EYE PROBLEMS ARE YOU EXPERIENCING? ____________________________________________________

______________________________________________________________________________

13.  YES or NO, do you need:     LENSES?___________              FRAMES?____________            EXAM?______________

14.    Date of last eye exam:_____________________ Doctors Name:_____________________________________

                                                                                                Address:____________________________________

15. ADDITIONAL INFORMATION (IF NECESSARY) THAT WOULD HELP DEMONSTRATE FINANCIAL NEED:

_______________________________________________________________________________

_______________________________________________________________________________

16.  AMOUNT APPLICANT CAN PAY TOWARDS EXPENSE:  $______________________

17. I, the APPLICANT, certify that this application is accurate and complete.  I hereby authorize any individual or
    organization to release to the _________________________ any information necessary to confirm statements
    made in this application.  In consideration of any aid which may be granted, I agree to hold the ________________ harmless from any injury resulting from treatment paid
    by them.

Applicant’s Signature__________________________________________________________________________________

_______________________________________________________________________________________________________________________

       ______________         CLUB CONTACT      ______________________________________    ________________________________

LIONS CLUB NAME                                                                           NAME                                                      PHONE NO.                                         DATE

_______________________________________________________________________________________________________________________

        HSB EYE CLINIC COORDINATOR                                                                                       DATE RECEIVED                               CLUB CONTACTED

Lions Club International

NH Multiple District - 44

Health Services Board 

Name:________________________________________________________________

An appointment of an eye examination has been scheduled for you

on ______________________________ at ______________________(AM/PM)

Where:  NH Lions Eye Clinic

NH Association for the Blind

25 Walker St

Concord, NH  03301

You must contact the Lions Club Coordinator named below, two days prior to your appointment date to confirm
that the Clinic has not been cancelled. 
Failure to do so could result in you making an unnecessary trip to the Eye Clinic.

It is necessary that you bring this form with you.

If you are 15 minutes late for your appointment you will have to be rescheduled on another date. 

            Lions Club Coordinator:  __________________________________

     Coordinator’s Tel #:        __________________________________        

     Address of Sponsoring Lions Club:  _______________________________________

  _______________________________________

     _______________________________________

Club Coordinators please indicate below where applicant should be sent for
eye glasses.

Send this applicant to:____________________________________________________

                                                                           _________________________________________________

                                                                           _________________________________________________

                                                                           _________________________________________________

From North Main Street at intersection of Rte 4/202, bear left onto Boulton St which becomes Daniel Webster Hwy. 
At traffic lights turn left onto Penacook St, go one block and turn left onto Bradley St, go one block and turn right
onto Walker St and take an immediate left into parking lot.

Brick building with chain link fence around parking lot.

For comments, additions, corrections, or general help from
The Lions of New Hampshire,
email: Webmaster@NHLions.org.
Please include city, state and country from which you are writing.