Vision Therapy Grant Application

We want your family to receive affordable vision therapy treatment. To apply, please follow these steps:

Fill out the online application form.
Submit your most recent tax return by email or mail.
Expect to hear from us within 4 weeks (Our foundation board has monthly meetings to approve or deny funding).
The Lumen Foundation will directly pay the clinic providing services to your family.

Patient Name

First Name

Last Name

Patient Date of Birth

YYYY

Vision Therapy Provider

Name of clinic providing services

Primary Diagnosis

Your vision therapy provider will give you a primary diagnosis.

Estimated Treatment Time (in weeks)

Your provider should give you an estimate for how long vision therapy should take to complete.

Parent/Guardian Name (if patient is a minor)

First Name

Last Name

Phone

(###)

###

####

Estimated non-covered cost:

Your vision therapy provider can give you an estimate for non-covered services. This estimate should NOT include any copays, deductibles, coinsurance, or out-of-pocket maximums.

Non-covered cost I am able to pay:

We will provide as much grant money as possible, but you will likely still have some out-of-pocket expenses. Let us know what you can contribute.

Vision Therapy Grant Application

The Lumen Foundation