If your student attends a school in the School District of Lancaster, please complete the application below. If you have any questions or concerns about the requested information, please contact Conestoga Eye at 717-541-9700 ext. 106. You can also download the application form here and return it to us.

All the fields below must be completed for the from to send. Please complete the below questions completely.



Vision screening and screening for amblyopia (lazy eye) consists of checking a child’s vision, and the performance of other tests such as photoscreening or other tests to detect a lazy eye. Medical Eye Examinations for those who fail screening includes, but is not limited to, dilation of eyes with eye drops, prescribing of eye glasses and careful examination of the eyes in the eye doctor’s office during school hours (2104 Spring Valley Road, Lancaster, PA 17602).
I hereby authorize KinderSee, its ophthalmologists, optometrists and staff to provide medical eye care to the above named child if indicated. I understand that no guarantees have been made concerning the above named child’s results of this vision screening, examination and treatment.
I understand that my consent is not required for KinderSee to use or disclose the above named child’s health information to and from the following parties, and this may include the following activities, and others:
1. Ophthalmic health care personnel or facilities for the purpose of providing treatment or evaluation of the above named child’s health related conditions, or for their payment activities.
2. To entities for treatment referrals such as the school health department, family independence agencies, health agencies and social service or assistance programs.
3. Any insurance company or third party payer, including government health care programs, for processing the claim and obtaining payment for the ophthalmic care provided, and for utilization review
4. To entities or business associates to perform health care operation activities on behalf of KinderSee including quality improvement, medical review, general business management and administrative activities.
I certify that the information given by me on behalf of the above named child in applying for payment under Title XIX, (Medicaid) of the Social Security Act or under any other governmental health care program or from any other third party payer is correct. Furthermore I authorize KinderSee to obtain the release from and to secure from anyone, medical, ophthalmic or other information about the above named child pertinent to qualify for Medicaid programs or benefits to release to and to secure from the Social Security Administration, the Pennsylvania State CHIP program or to other agencies or entities administering the Medicaid programs, or to intermediaries or carriers any information that is needed for this or a related Medicaid claim. I request that payment of authorized benefits be made on the behalf of the above named child to KinderSee for reimbursement for such ophthalmic care and treatment provided to the above named child.
I understand that the school is responsible for transportation of the above named child to and from KinderSee and if the above named child is injured during transportation to and from KinderSee or Family Eye Group, I release and hold harmless KinderSee on behalf of myself and the above named child, from any and all liability for personal injury.
I have read this consent for treatment, or have had it explained to me. I am the child’s parent/guardian and I am authorized to consent on behalf of the above named child.

By completing my name below, I acknowledge that I have read and hereby give consent for the treatment of my child.

By completing my name below, I acknowledge that I have received and read a copy of the Notice of Privacy Practice. (Found here.)

If your family meets or is under the listed annual incomes for your household size, your child is eligible for KinderSee. If you family exceeds this income, more information is needed. In both cases, a form will be sent to you to verify your income.

Household Size  = Annual Income 
1 = $23,760
2 = $32,040
3 = $40,320
4 = $48,600
5 = $56,880
6 = $65,160
7 = $73,460
8 = $81,780
For each additional person add: $8,040

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