GUIDELINES FOR PATIENT REFERRAL

NOTE: Scroll down for FORMS

1. Patient Eligibility

º Must have one year's continuous residency in the communities served by the Foundation.

º Income: Annual ADJUSTED GROSS INCOME from line 37 on Form 1040, line 4 on Form 1040EZ, or line 21 on Form 1040A, must be less than (Effective May 1, 2014):


                                             Family Size:               1               $29,175
                                             Family Size:               2               $39,325
                                             Family Size:               3               $43,385
                                             Family Size:               4               $47,445
                                             Family Size:               5               $51,505
                                             Family Size:               6               $55,565
                                             Family Size:               7               $59,625
                                             Family Size:               8               $63,685

º Proof of Income Required: (1) Front page of most recent tax return, or (2) two most current paystubs, or (3) if you have no reportable income, a letter explaining how you are paying for current living expenses.

º Insurance: patient has no insurance (no county, government, or private coverage, no partial coverage, share-of-cost or deductibles)

º Total assets: if total is more than $75,000, services may be denied.

2. Doctor's or Clinic's Responsibility

º It must first be determined that the patient does indeed have an eye problem that requires treatment and care (excluding eye glasses and contact lenses). A referral from a doctor stating the patient's diagnosis is required.

º Lions Eye Foundation does not provide assistance for glasses or contacts.

º Make sure the Physicians Referral Form is sent to a member club. If you are not in contact with a member club, go to "MEMBER CLUBS" on this website, find a club listed by community, and send the form to the attention of "Sight Conservation Chair".

º Failure to go through a member Lions club will result in considerable delays.

3. Club's Responsibility

º Completion of Physician Referral form, Patient Financial Statement and Patient Release of Information (must be signed by doctor, patient and club representative accordingly).

A referral letter from the physician may be used in lieu of doctor signature.

º Submitting incomplete forms will result in considerable delays. If in doubt, contact the Lead Trustee in your District for help.

º If possible, provide assistance for transportation to and from appointments in San Francisco (BART, train, bus, money for gas, etc) as needed. LEF will reimburse clubs a portion of the mileage cost (one-way only) after the appointment has occurred.

For Transportation Reimbursement Request form PLEASE CLICK HERE.

For Transportation Reimbursement instructions PLEASE CLICK HERE.


º If needed, provide glasses after patient has completed treatment/surgery.

4. Questions

º Call Lions Eye Foundation at (415) 600-3950.

º Email: PaskvaM@sutterhealth.org (Mark Paskvan, Program Coordinator)


º FAX: (415) 600-3949

º Emergency cases (retina detachments, foreign objects in eye, etc.) call Mark as soon as possible to expedite referral.

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