Submit Your Application
Complete our secure online intake form by answering a few quick questions about your medical condition and how sunlight or glare affects your daily driving. The application is fully online, simple to complete, and gives your licensed provider the information needed to review your submission.
What to Expect
- Completing the application takes just a few minutes.
- Have your basic personal information ready before you begin.
- You'll receive confirmation once your application is submitted.
- No payment guarantees approval. Every submission is reviewed individually by a licensed provider.