EYE SURGERY FUND APPLICATION
QUALIFICATIONS AND PROCEDURE
Eye Surgery Fund Overview
The Eye Surgery Fund is a project of the board of directors of the Rocky Mountain Lions Eye Bank (RMLEB). It is a cooperative effort with the Lions clubs and Ophthalmologists of Colorado and Wyoming.
The primary purpose of the Eye Surgery Fund is to provide funding for surgery for applicants who would otherwise go blind. Funding is available for eye surgeries for residents of Colorado and Wyoming who are financially unable to obtain medical treatment. Primary attention shall be paid to financial status, no insurance coverage for the requested procedure, and residency.
All applications must originate with the local Lions club.
The applicant (parent/guardian) MUST be unable to pay for eye surgery and not qualify for other assistance such as Medicare or Medicaid. All other avenues of funding should be sought prior to application for Eye Surgery Fund financing. The ESF is for SIGHT-SAVING SURGERY ONLY.
Applicants seeking corneal transplants shall have top priority.
The local Lions club works in combination with the RMLEB-ESF, Ophthalmologists, anesthesiologists and surgical facilities willing to provide discounted services to patients with demonstrated financial need and no insurance coverage for the requested procedure.
Applicant Qualification and Funding Availability
Effective January 1, 2016, the Eye Surgery Fund will adhere to these requirements:
Applicants must be US citizens and must reside in our service areas-Colorado and Wyoming.
Applicants must agree to a one-on-one interview with the sponsoring Lions club representative.
The applicant must be willing to provide all financial information requested by the sponsoring Lions club representative. The applicant must sign the HIPPA disclosure in the presence of a Lions Club representative. The applicant must be willing to provide any eligibility information requested by the sponsoring Lions club representative.
The Eye Surgery Fund shall provide funding for the surgery only. The cost of office visits, supplies, etc. shall be provided from outside sources. A minimum of 40% of the total Medicare rate of each surgery must come from sources other than the Eye Surgery Fund. The Eye Surgery Fund shall provide up to 60% of the Medicare rate of each surgery.
All applications shall be considered on a first come, first serve basis. Emergency funding will not be available and applications will be approved at regular meetings of the board of directors only.
Only completed applications will be considered. Completed applications must be in the hands of the director by 5PM, 14 working days prior to the regularly scheduled ESF committee meeting. A schedule of these dates for the fiscal year appears elsewhere in this web page. After a review by the assigned RMLEB board director, the application will be reviewed by the Chairman of the ESF committee and presented at the committee meeting. The decision of the board regarding the application will be sent to the Responsible Lion. The Responsible Lion will then notify the applicant and the surgeon’s contact person. The surgery then can be scheduled.
Upon completion of the surgery, the surgeon’s contact person must complete the Verification of Surgical Treatment and send this form to the Chairman of the ESF committee for payment.
Payment of the ESF portion of the surgery shall be sent to the sponsoring Lions club. The sponsoring Lions club is responsible for all bills for the surgery.
Revisions have been made to the ESF application and can be downloaded from this website.
Application Overview and Procedure
All applications shall originate with the applicant contacting a local Lions club willing to
Sponsor the application.
It is the responsibility of the Responsible Lion to complete the Applicant Portion, the Sponsoring Club Portion and the Cover Sheet. The Responsible Lion will confirm eligibility of the applicant as outline in these instructions, will work with the surgeon’s contact person in regard to the type of surgery needed and the rates accepted for the surgery. Once the cost of the surgery has been determined, the Responsible Lion will provide sufficient information to confirm that all portions of the cost of the surgery will be covered.
Upon receipt of final approval from the Chairman of the ESF committee, the Responsible Lion shall inform the applicant and provide approval confirmation to the surgeon’s contact person. The surgery can then be scheduled.
Following completion of the surgery, he/she shall assist the surgeon’s contact person in completing the Verification of Surgical Treatment. Once he/she received the funds from the ESF, he/she will insure that all costs of the surgery are paid. In summary, the Responsible Lion must be sure that all expenses connected with the surgery are paid.
Help in completion of any part of the ESF application is available from the District Eye Bank Director. District directors are listed on the RMLEB website www.corneas.org or in the MD6 or District 15 directories.
Cover Sheet-This portion is completed by the Responsible Lion and is a summary of the application. The portion within the box and items below are completed by the EB board director submitting the application.
Applicant Portion-This portion determines the applicant’s eligibility. It also includes Identification and Consent for Use and Disclosure of Personal and Health Information. This portion must be completed by the Responsible Lion and include his/her signature as well as the applicant’s signature or the signature of the legal representative. The applicant must have pursued all available existing support such as Welfare, SSI, Medicare, Veterans benefits, etc.
Medical Portion-This portion certifies medical need. This portion is completed by the contact person for the surgeon. The Responsible Lion works with the applicant and ophthalmologist to complete this Certification of Medical Need. The surgeon, surgical facility and anesthesiologist must be willing to discount or waive their fees. Each director has a list of the most common surgeries, the Medicare codes and the maximum allowable Medicare rate that the board will consider. Any surgeries not included in this list will be considered on a case by case basis.
Sponsoring Lions Club Portion-This portion determines the sponsorship of the applicant by the local Lions club. A brief history of the clubs association with the applicant shall be completed. Since this is a cooperative effort, some financial assistance is requested from the local Lions club and/or other sources.
Help in completion of any part of the Eye Surgery application is available from your district Eye Bank director.
Once the Responsible Lion has completed the application, it should be delivered to your district Eye Bank Director.
The application must be received by the EB Director no later than 5PM, 14 working days prior to the ESF committee meeting.
After a review by the Director, copies of the application will be forwarded to the Chairman of the Eye Surgery committee and to the Eye Bank Executive Assistant along with an ESF Worksheet summarizing all elements of the application. This process must occur no later than 5PM, 4 working days prior to the ESF committee meeting.
The application will be presented by your director at the by-monthly RMLEB-ESF committee meeting with the original signed copy of the application being presented to the Chairman of the committee.
Following the aforementioned meeting, your director will notify the Responsible Lion regarding the status of the application. Official notification of the board’s decision will be mailed to the Responsible Lion, with a copy to your director, within 4 working days of the board meeting. This document may be used when notifying the surgeon’s contact person.
The Responsible Lion needs to provide the surgeon’s office with the ESF Verification of Surgical Treatment form.
Following the surgery, the Responsible Lion will notify his/her district EB director. The surgeon’s contact person shall complete the ESF Verification of Surgical Treatment. It is imperative that the Cost of Treatment include ALL fees for the surgery because payment will be based upon this figure. This form should be faxed to the Chairman of the Eye Surgery Committee.
The current Chair of the ESF committee is: Lion Carole Kitchell
Upon receipt of said Verification, the Chairman of the ESF committee shall disperse funds, 1 check per surgery, to the sponsoring Lions club. Said payment shall be mailed to the Responsible Lion at the address provided on the Cover Sheet with a copy to the director or to the director if specified.
The Responsible Lion shall deliver all funds for full payment of the surgery. It may be necessary for the Responsible Lion to acquire funds from the other sources and for the club treasurer to make payment to more than one entity involved with the surgery.
Any notification of non-payment of surgery shall result in the Chairman of the ESF committee notifying the director who will in turn notify the Responsible Lion. The Responsible Lion MUST be sure that all expenses connected with the surgery are paid.