Tip for New Eyes Application

Individuals cannot apply directly — a social worker, caseworker, school nurse, or healthcare professional must submit on your behalf

Tip for New Eyes Application

The program provides basic prescription eyeglasses — not designer frames or contact lenses

Tip for New Eyes Application

If you have Medicaid, Lions Club, or other vision resources available, you must use those first

Dental, Vision & Hearingeasy

New Eyes Voucher Application

New Eyes Application · New Eyes (nonprofit)

Application for vouchers for prescription glasses for individuals with low income. Must be submitted by a social worker or case manager on behalf of the client.

Form Details

Total fields: 20
Auto-fillable: 14 (70%)
Time without BeneFill: 20 minutes
Time with BeneFill: 6 minutes
Time saved: 14 minutes
Filled by: caregiver
Frequency: one time

Fill this form with BeneFill

Auto-fill 70% of fields from your profile. Save 14 minutes. Download a real PDF.

14 of 20 fields70% auto-filled

Start Filling Upload Your Copy Instead

Where to Submit This Form

📬

Mail application to New Eyes

New Eyes for the Needy 549 Millburn Avenue P.O. Box 332 Short Hills, NJ 07078

Applications must be submitted by a social service agency, not by the individual.

Filing Deadline

Applications are accepted on a rolling basis. Must be submitted by a referring social service agency, school nurse, or healthcare professional.

Required Attachments

📎 Completed New Eyes voucher application (signed by referring agency caseworker)
📎 Current eyeglass prescription (less than 1 year old) from a licensed optometrist or ophthalmologist
📎 Documentation of financial need
📎 Proof that the applicant has no other resources for eyeglasses (no Medicaid, no VSP, no Lions Club assistance)

Processing Time

2-4 weeks for application review. If approved, a voucher is sent to the referring agency.

What Happens Next

If approved, a purchase voucher is sent to the referring agency. The client takes the voucher and prescription to a participating optical retailer to receive glasses.

Tips for This Form

✓ Individuals cannot apply directly — a social worker, caseworker, school nurse, or healthcare professional must submit on your behalf
✓ The program provides basic prescription eyeglasses — not designer frames or contact lenses
✓ If you have Medicaid, Lions Club, or other vision resources available, you must use those first
✓ New Eyes also accepts donated glasses for distribution to people in developing countries

More Dental, Vision & Hearing Forms

Medicaid Dental Authorization / Claim Form

State-specific · State Medicaid agencies / dental MCOs

Prior authorization or claim form for Medicaid dental services. Coverage varies significantly by state; some states limit adults to emergency dental only.

ADA Dental Claim Form

J400/J430/J432 · American Dental Association

Standard dental claim form used for billing all dental insurance plans. Includes pre-treatment estimates and procedure codes.

Donated Dental Services Application

DDS Application · Dental Lifeline Network / ADA

Application for free comprehensive dental treatment through volunteer dentists for people who cannot afford treatment due to disability, age (65+), or medical condition.

Medicaid Vision Benefit Authorization

State-specific · State Medicaid agencies

Authorization for Medicaid-covered vision services. Coverage varies widely by state, with some limiting to one exam every two years or glasses only after cataract surgery.

Lions Club Hearing Aid Program Application

Local club application · Local Lions Clubs

Local program distributing refurbished or low-cost hearing aids to those in need.

Medicaid Hearing Aid Authorization

State-specific · State Medicaid agencies

Authorization for Medicaid-covered hearing aids and audiology services. Not all states cover hearing aids for adults.

Not sure which forms you need?

Tell our assistant about your situation and we'll find the right forms for you.

Chat with Form Assistant

Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the New Eyes (nonprofit) or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.