Eye Care for Kids Foundation Claims
Approval Code:
Date of
Service:
(*Include RX if making a claim for High RX Poly)
Total Amount For Services Rendered:
Total Parent
Contribution:
Total In-Kind Contribution:
Services Rendered:
Parent
Contribution:
Doctor's In-Kind Contribution:
Total Amount Due Minus Parents' Contribution: (if applicable)
Please note, we have removed the "submit" button from this page.
Please fill out this form, print it  and fax it with program applications to 713-728-9304
or mail with applications to Eye Care for Kids, 9660 Hillcroft, Ste 325, Houston, TX 77096.