Medical Assistance LCF-I CompanyThis field is for validation purposes and should be left unchanged.Date of Application MM slash DD slash YYYY Purpose of RequestIs this Request an emergency? Yes No Medical Assistance Type(Required) Medical Assistance Eyecare Hearing Aids Cataract Surgery Prosthetic Eye Cataract Surgery Left Eye Right Eye Both Eyes Prosthetic Eye Left Eye Right Eye Describe the Medical Assistance RequestWhat is the cost?If available, upload a PDF supporting document.Accepted file types: pdf, Max. file size: 32 MB. Only one PDF document under 100MB can be uploaded.Recipient InformationName First Last SSNGender Female Male Number of DependentsDependent 1 AgeDependent 2 AgeDependent 3 AgeDependent 4 AgeHome PhoneWork PhoneEmail Address Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Financial InformationMonthly IncomeEmployment IncomeFood StampsSocial SecurityAlimonyChild SupportRetirementOther IncomeTotal Monthly IncomeAuto-Calculated ValueMonthly ExpensesRent/MortgageFoodElectric/GasAlimonyWater/SewerInternet/CableCar/Home/Life InsurancePhoneChild SupportTotal Monthly ExpenseAuto-Calculated ValueDo you have any family who would assist with the payment of your medical bills? Yes No AmountNameInsurance InformationPlan Name*Policy / Claim / Case No.*Group No.*Plan Effective Date MM slash DD slash YYYY Physician InformationHas recepient been by a physician? Yes No Physician NameHas recepient had a second opinion? Yes No Physician NameActions of Lions ClubsIs your Lions Club assisting financially with this project?(Required) Yes No Lion Club NameAmountAre other Clubs in the Zone / Region / District assisting financially with this project?(Required) Yes No Lion Club NameAmountAre other charitable organizations considering sharing the cost?(Required) Yes No Organization NameAmountHas the family received assitance before?(Required) Yes No WhenOrganization NameHas any Lions Club member personally interviewed this person and verified the information?(Required) Yes No Date of Visit MM slash DD slash YYYY Estimated total cost of this Medical Assistance(Required)Hearing Aid Co-PayCo-Pay is $250 ($125 per ear).Hearing Aid Co-Pay Price: Prosthetic EyeCo-Pay is $100Prosthetic Co-Pay Price: Cataract SurgeryCo-Pay is $100 (per eye procedure).Cataract Surgery Co-Pay Quantity Price: $100.00 Quantity Total Cataract Surgery Co-Pay Payment Options Mail Check written to Lions Charity Foundations of Southeastern Virginia Inc. and mailed to Treasurer, 1420 Ski Lodge Rd, Virginia Beach, VA 23453 Credit Card PaymentCredit Card MasterCardVisaSupported Credit Cards: MasterCard, Visa Card Number Expiration Date Security Code Cardholder Name Club Information & AcknowledgementClub Requesting Medical Assistance(Required)Club Representative(Required) First Last Club Representative Email Address(Required) Club Representative Position(Required) President Secretary Other Club Representative Phone(Required)Club Representative SignatureTo sign, click & hold the left mouse button or press & hold your finger inside the dashed box to draw. To clear, click the gray icon in bottom-right corner.
