Elders Vision Reimbursement Application

The Elders Vision Program can only be accessed one (1) time each calendar year.

This program is open nationwide to all LTBB citizens aged 55 and older.

This program covers $200 for an eye exam and $300 for frames, lenses, and/or contacts.

-Glasses/contacts do not need to be purchased at the time of the appointment.

-Each year a maximum of $300 can be reimbursed for one or multiple pairs of frames, lenses, or contacts

The Elders Vision Program is considered the PAYER OF LAST RESORT. This means all other insurance must be billed before the Elders Vision Program issues payment.

The Elder is responsible for completing and submitting this application in its entirety, including submitting any insurance information and the itemized statement/receipt showing payment.

I am applying for reimbursement of the following services: *

Vision Exam

Contacts/Glasses

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Tribal ID # *

Preferred Contact Method: *

Email Address

Attach your payment receipt here: *

Attach any insurance card(s) here:

I UNDERSTAND THAT FAILURE TO FOLLOW THESE INSTRUCTIONS WILL RESULT IN MY APPLICATION BEING DENIED. I ALSO UNDERSTAND PROVIDING FALSE INFORMATION CAN RESULT IN REFERRAL TO THE PROSECUTING ATTORNEY FOR FRAUD, AND/OR RECOVERY OF FUNDS PAID ON MY BEHALF.

I certify that the information provided is complete and correct: *

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IF YOU HAVE ANY QUESTIONS YOU CAN CONTACT:

Abigail Dawson

231-242-1752

adawson@ltbbodawa-nsn.gov