Vision Form Step 1 of 4 25% Member Information Enter Member Id and Date of Birth to validate Member before proceeding with the form. Member's ID#* Member's DOB* MM slash DD slash YYYY Date item was or will be dispensed MM slash DD slash YYYY Member's Name* First Last Error Message Provider InformationProvider’s Group NPI* 10 digitsProvider’s Group Name* Error Message Contact Name* Contact Phone #*Contact Fax #*Email address in order to receive confirmation of request receipt* Clinical Information The test must be for the benefit of the member in that the test results will have an impact on and make a change in the member’s clinical management. The sensitivity of the test must be greater than the clinical pre-test probability of the diagnosis. HCPC/CPT Code (Click + or - at the right to add up to 5 Codes)*Code TypeCodeUnits Example HCPC code: S1234 with modifier: S1234 U1 Example CPT code: 12345Diagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890What is being requested?*What is being requested? *Progressive LensesPolycarb Lenses for Adults *Please note – under 21 years of age does not require authorizationPolychromic LensesOtherServices requested; Instructions: Please select requested service and check Yes or No*Services requested; Instructions: Please select requested service and check Yes or No *Replacement Lenses age 21 years old and over (Eyeglass frames are covered only every 2 years)High Index LensesPunctal PlugsContact LensesChange in refraction of at least 0.5 diopter (lens spherical equivalent)*Change in refraction of at least 0.5 diopter (lens spherical equivalent) *YesNoPrescription is (-10) or above and lens does not fit into frame*Prescription is (-10) or above and lens does not fit into frame *YesNoHistory of using artificial tears*History of using artificial tears *YesNoTrial use of collagen plugs which dissolve in 7-12 days with success, i.e. symptom relief*Trial use of collagen plugs which dissolve in 7-12 days with success, i.e. symptom relief *YesNoHigh myopia*High myopia *YesNoKeratoconus that cannot be corrected with glasses*Keratoconus that cannot be corrected with glasses *YesNoAnisometropia with diopter difference >3. (Difference in the power of required lens power of the two eyes of greater than a spherical equivalent of 3 diopters)*Anisometropia with diopter difference >3. (Difference in the power of required lens power of the two eyes of greater than a spherical equivalent of 3 diopters) *YesNoAphakic Contact Lens for aphakia*Aphakic Contact Lens for aphakia *YesNo Signature of Physician or Licensed Provider (Required for skilled service)*Signature Date:* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 23 MB.Upload only PDF or Word filesSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA