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Prescription Eyeglasses
Assistance Form

Get Help Paying for Prescription Eyeglasses.

Apply for financial assistance with an eye exam and/or prescription eyeglasses.

Complete this form to apply online.

Standard Awards and Limits - Featured Providers

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Exam Only

Can pay up to $70​

  • For clients who need a current prescription before ordering

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America's Best

This vendor provides low- cost exams and glasses.

Client obtains quote or order details and staff pays the approved ammount directly to the vendor.

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 Glasses Only

Can pay $80 to $120​

  • For clients who already have a valid prescription.

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Walmart Vision Center - Walmart.com

This vendor provides low- cost glasses when you already have a prescription.

Client submits a cart or quote, CBS staff reviews, and pays after approval.

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Exam & Glasses

Can pay $120 to $150​

  • Best for bundled low-cost providers

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Local or Online Optometry Partners

Other providers can be used.

How It Works

  1. Complete the online application

  2. Upload your documents

  3. CBS staff review your eligibility

  4. Once accepted, choose from approved low-cost providers

  5. Submit your quote, cart, or order details

  6. The program pays the approved amount directly to the vendor when possible.

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Prescription Eyeglasses Assistance Program Form

  1. Client Information
Preferred Language?
English
Spanish
Other
Gender?
Male
Female
Other
Ethnicity?
Hispanic
Black
Asian
White
Other
Check all that you receive:
  1. Household & Income Information
  1. Eligibility Screening
Do you live in Los Angeles County?
Yes
No
Are the glasses for you or a family member?
Yes
No
  1. Vision & Prescription Details
Select the option that fits your current needs:
I have an eyeglasses prescription I need help paying for
I need help paying for an eye exam
I need help paying for an eye exam and prescription glasses
  1. Consent to Contact
I agree to be contacted by CBS regarding my request for assistance.
I agree

Submitting this form does not guaranteed eligibility for benefits or services. CBS provides information, screening, referrals, and application/enrollment assistance. Official eligibility decisions are made by program agencies.

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