Doctor

I confirm that I have approval from my institution and/or practice to participate as an All Children See (ACS) volunteer.

I agree to provide a comprehensive, medical eye examination and necessary non-surgical treatment to children who are U.S. legal residents or citizens under the age of 18, at no cost to patients referred to me through ACS. I agree to provide follow-up care for up to one (1) year for any condition diagnosed during the initial examination, at no cost to patients referred to me through ACS.

I acknowledge that All Children See does not provide or fund surgical care. If a patient requires surgical intervention or treatment beyond the scope of my services, I agree to direct the patient to charity care or financial assistance programs at my facility.

I understand that I may request reimbursement from ACS for eligible expenses related to eyeglasses and/or patching, in accordance with ACS policies.

I agree to complete the online ACS patient outcome form after seeing each patient referred to me through ACS.

I understand that any ACS-related care provided beyond the initial one-year follow-up period is optional and will be determined on a case-by-case basis between myself and the patient.

Doctor (Volunteer Form)

Enter address(s) below where you will serve ACS patients