EyeCare America Resident Volunteer Pledge Form
I am an ophthalmology resident, dedicated to giving back to my community through volunteerism. Once I become a practicing ophthalmologist, I pledge to enroll as an EyeCare America volunteer. Keeping within my practice office policy, I will choose from the programs listed below.
EyeCare America, an American Academy of Ophthalmology program that is one of the country’s largest public service programs, provides eye care through a pool of more than 5,500 volunteer ophthalmologists, who give back to their community without leaving their office. Since 1985, the program has helped nearly 2 million people.
(Once you are a practicing ophthalmologist, you may choose one or all that apply.)
1) Seniors Program: I will provide a comprehensive, medical eye exam to EyeCare America referred seniors (65 or older) and care for up to one year for any condition diagnosed during the initial exam—at no out-of-pocket cost to EyeCare America patients. I will accept Medicare and/or other insurance reimbursement as payment in full; waiving co-payments and/or unmet deductibles as provided for by EyeCare America’s waiver issued by the Health and Human Services Office of the Inspector General. EyeCare America patients without insurance receive care at no charge. I agree to contact EyeCare America if I find a patient needs to see a subspecialist or care I am unable to provide.
2) Glaucoma Program: I will provide a glaucoma eye exam, and initiate treatment, if deemed necessary. Patients with insurance will be billed and are responsible for any co-payments. Patients without insurance receive this care at no charge. This is an early-detection awareness program good for one visit for EyeCare America referred patients who are determined to be at increased risk for glaucoma (determined by their age, race and family history).
3) Retina Re-referral: I will provide care for EyeCare America seniors program patients who need to receive retinal care that the original referred doctor is unable to provide. Patient care is the same as the seniors program.
EyeCare America volunteers agree to see no more than 15 EyeCare America patients per fiscal year (April 1 to March 31) for each of the above.
Enroll as a volunteer:
Thank you for your support of EyeCare America