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Eye Surgery Fund


The Eye Surgery Fund is a project of the board of directors of the Rocky Mountain Lions Eye Bank. It is a cooperative effort with the Lions clubs and ophthalmologists of Colorado and Wyoming. 

The Eye Surgery Fund (ESF) provides funding for surgery to 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. The ESF is for sight-saving surgeries only. 

Please carefully read these instructions.  

Download and print the instructions

Qualifications & Process
  • All applications must originate with a local Lions Club.
  • All applications are on a first-come, first-serve basis.
  • Applicants seeking corneal transplants shall have top priority.
  • Only completed applications will be considered.
  • Applications are only approved at regular meetings of the RMLEB board of directors. Emergency funding will not be available.
  • The local Lions club must work with the 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. 
  • The ESF shall provide funding for the surgery only. The cost of office visits, supplies, etc. are not covered by the ESF. A minimum of 40% of the total Medicare rate of each surgery must come from sources other than the ESF. The ESF shall provide up to 60% of the Medicare rate of each surgery. 
  • Completed applications must be in the hands of the RMLEB board director by 5 pm, 14 working days prior to the regularly scheduled ESF committee meeting.
  • The decision of the RMLEB 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 can then be scheduled.
  • Upon completion of the surgery, the surgeon's contact person must complete the Verification of Surgical Treatment. The Responsible Lion must then send the form to the Chairman of the ESF committee for payment.
  • The payment of the ESF portion of the surgery will be sent to the sponsoring Lions club.
  • The Responsible Lion must ensure all expenses related to the surgery are paid.
Applicant Requirements
  • Must be a US citizen and reside in the RMLEB service area of Colorado or Wyoming
  • Must be unable (or parent/guardian 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 completing the application for ESF funding.
  • Must contact their local Lions club to sponsor the application and surgery
  • Must agree to a one-on-one interview with a representative from the sponsoring Lions club
  • Must be willing to provide all financial information requested by the sponsoring Lions club representative
  • Must be willing to provide any eligibility information requested by the sponsoring Lions club representative
  • Must sign the HIPAA disclosure in the presence of the sponsoring Lions club representative
Application Overview

All applications shall originate with the applicant contacting a local Lions club willing to sponsor the application.

It is the function of the Responsible Lion to complete the Applicant Portion, the Sponsoring Club Portion and the Cover Sheet. The Responsible Lion will confirm the eligibility of the applicant as outlined 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 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 the completion of the surgery, the Responsible Lion will assist the surgeon’s contact person in completing the Verification of Surgical Treatment. Once the Responsible Lion receives the funds from the ESF, the Lion will ensure all costs of the surgery are paid. In summary, the Responsible Lion must ensure all expenses connected with the surgery are paid.

A RMLEB board director can assist with, or answer any questions, related to the process or application. Directors are listed here or in the MD6 or District 15 directories.

Cover Sheet- Completed by the Responsible Lion and is a summary of the application. The portion within the box and items below it are completed by the RMLEB board director submitting the application.

Applicant 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, Veteran's benefits, etc.

Medical Portion- Certifies medical need. This portion is completed by the surgeon's contact person. The Responsible Lion works with the applicant and ophthalmologist to complete the 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- Determines the sponsorship of the applicant by the local Lions club.  A brief history of the club's association with the applicant shall be completed. Since this is a cooperative effort, some financial assistance is requested from the local Lions club.

A RMLEB board director can help with the completion of any part of the Eye Surgery application.

Application Procedure

Once the Responsible Lion has completed the application, the Lion should send it to the appropriate district board director.

The application must be received by the board director no later than 5 pm, 14 working days prior to the ESF committee meeting.

After a review by the board 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 5 pm, 4 working days prior to the ESF committee meeting.

The application will be presented by the 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, the 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 the 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 the board 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 sent to the Chairman of the Eye Surgery Committee.

Lion Carole Kitchell is the current Chair of the Eye Surgery committee.

Upon receipt of said Verification, the Chairman of the Eye Surgery committee shall disperse funds, one 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 also provided to the board director.

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 Eye Surgery committee notifying the board director who will, in turn, notify the Responsible Lion. The Responsible Lion MUST ensure all expenses connected with the surgery are paid.

Download the Application