Health Benefits Program Application

Health Benefits Program

MCB provides financial assistance to legally blind citizens of Missouri and members of MCB who experience illness or accident resulting in loss of income.

$45/week

Benefit amount

$450/year

Maximum (10 weeks)

Benefits begin on the 8th day following the illness or accident
Must be under care of a licensed physician
Application must be submitted within 90 days of the last date on the physician's statement
Non-members who are legally blind receive 50% of benefits

Supporting documents required (submit separately): Physician's statement, visual status statement (non-members), and signed medical records release form. Mail or email to aa@moblind.org.

Required field — This is Part 1 of the application. Supporting documents must be submitted separately.

Personal Information

First Name

Last Name

Phone

Mailing Address

Address Line 1

Address Line 2

City

State

ZIP Code

Vision & Membership Status

Vision Status

MCB Membership Status

Which affiliate? (if affiliate member)

Illness or Accident Information

Brief Description of Illness or Accident

Start Date of Illness/Accident

End Date

Applicant Signature

Full Name (Electronic Signature)

By typing your name, you certify all information is accurate and release MCB to verify your claim.

Paper Form

Download PDF Form

Mail to:

Missouri Council of the Blind
Health Benefits
5453 Chippewa Street
St. Louis, MO 63109

Documents Required

After submitting this form, also send:

Physician's statement
Visual status statement (non-members)
Medical records release form (signed)

Email: aa@moblind.org

Need Assistance?

(314) 832-7172

(800) 342-5632

moblind@moblind.org