Application and Guidelines
Click here for an English Application Click here for a Spanish Application
To apply for medical or surgical, specialty 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. Listed on the last page of the application are a few of the most requested phone numbers for local counties.)
2.) Copy of most recent household tax return. (If household files income taxes)
3.) Copy of last two paystubs that includes year to date figures for all working individuals in the household, or a handwritten letter from employer. If self-employed, please provide a self-employment letter confirming occupation type and monthly gross income. If unemployed, a copy of any financial award letters from disability, social security or unemployment offices. If unemployed and living with family members, send proof of household income for the family and letter from family confirming they are financially supporting the applicant.
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.
To apply for Eye Care for Kids Vision Program, applicant must complete the HEA Foundation application and send with the following documents:
(**This program is only for patients 21 and under.)
1.) Copy of most recent household tax return. (If household files income taxes)
2.) Copy of last two paystubs that includes year to date figures for all working individuals in the household, or a handwritten letter from employer. If self-employed, please provide a self-employment letter confirming occupation type and monthly gross income. If unemployed, a copy of any financial award letters from disability, social security or unemployment offices. If unemployed and living with family members, send proof of household income for the family and letter from family confirming they are financially supporting the applicant.
Please Note
- Only send copies with your application; documents will NOT be returned to the applicant.
- Application and documents may be faxed to (713) 558-8760, mailed to HEA Foundation, 7155 Old Katy Road, N100, Houston, Texas 77024, or emailed to heaf@houstoneye.com
Upon acceptance into the HEA Foundation Program:
- Patients acknowledge they are responsible for transporation to and from appointment. Physicians are located throughout 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 (713) 558-8740.
7155 Old Katy Road, Suite N100, Houston, Texas 77024
