Application and Guidelines
To apply for medical or surgical eye care services, applicant must complete the HEA Foundation application and send with the following documents:
1.) A current county denial letter from the residing county indigent medical program is required.
NOTE - Patient may live in any county within Texas or its surrounding states. Listed below are a few of the most requested phone numbers for local counties.
- Angelina County - 936-634-5431
- Bowie County - 903-614-5550
- Brazoria County - 979-864-1884
- Chambers County - 409-267-8306
- Colorado County - 979-732-9453
- Fort Bend County - 281-341-6624
- Galveston County - 409-770-5550
- Gillespie County - 830-990-7567
- Hardin County - 409-246-5189
- Harris County - 713-566-6691
- Jasper County 512-458-7706/409-423-6935
- Jefferson County - North: 409-835-8530 South: 409-938-8380
- Liberty County - 936-336-4693
- Matagorda County - 979-245-8421
- Montgomery County - 936-523-5100
- Orange County - 409-882-7838
- San Jacinto County - 936-653-2091
- Trinity County - 936-642-1736
- Waller County - 979-826-7730
- Walker County - 936-291-3411
- Wharton County - 979-595-2800
2.) Copy of household 2015 1040 filed tax return. If tax return is unavailable, send proof of income, such as a W-2 or a handwritten letter from employer or supporting family/friend confirming applicant's income. If unemployed or living with family members or friends, proof of household income for the family.
3.) Copy of the last two paystubs that include year to date figures for all working individuals in the household or a copy of any financial award letters from disability, social security, or unemployment office. If paystub or award letter is unavailable or if applicant is being supported by another individual, please complete the Financial Support Document.
4.) If applicant has private, medical insurance, a copy of the insurance card and a copy of the insurance plan stating the deductible is required.
5.) If applicant is younger than 18 years of age, a denial from MEDICAID/CHIPS is required.
6.) If applicant is older than 65 years of age or is receiving disability, a denial letter from MEDICARE/MEDICAID is required.
- Only send copies with your application; documents will NOT be returned to the applicant.
- Application and documents may be faxed to (713) 395-1666 or mailed to HEA Foundation, 7155 Old Katy Road, N100, Houston, Texas 77024.
Upon acceptance into the HEA Foundation Program:
- Patients must be willing and prepared for at least 5 to 6 visits with their assigned ophthalmologist. All participating physicians are located within the Greater Houston area.
- Patient may be asked to sign a media release waiver in efforts to share their experience with local funders.
- Medical and surgical eye services will be valid for 12 months before applicant must reapply for continued services. Some exceptions of the 12-month service may apply for various applications.
- Early termination may take place if patient misses scheduled appointments, does not follow physician's orders or remain compliant while under their care, financial assets are not completely disclosed and/or if the patient does not live in the United States permanently.
Houston Eye Associates Foundation is a 501 (c)3 non-profit organization committed to preserving and restoring the sight of those in need. For more information, please contact Jessica Tegethoff at firstname.lastname@example.org or (713) 558-8740.
7155 Old Katy Road, Suite N100, Houston, Texas 77024