Get Medically Necessary Contact Lens Prior Approval Form

Completing the Medically Necessary Contact Lens Prior Approval Form online can be a straightforward process if you follow the steps outlined in this guide. This form is essential for requesting approval for necessary contact lens services, ensuring that all relevant information is accurately captured.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In the Patient Information section, clearly print the patient's name and date of birth. Ensure that the Member/Patient ID Number is entered accurately. Indicate whether the patient is new by selecting 'Yes' or 'No'. Input the Group/Employer Name as needed.
3. Proceed to the Provider Information section. Clearly print the provider's name and include the provider's telephone and fax numbers. Additionally, provide the provider panel number and today's date.
4. In the Services Requested section, select the appropriate diagnoses and services by checking the relevant boxes such as 'Contact Lens Evaluation' or 'Keratoconus'. If applicable, specify any other services in the provided space.
5. Include any necessary additional comments from the provider in the Provider Comments section. Attach supporting documents as required.
6. In the Prescription Information section, fill in the detailed prescription for eyeglasses and contact lenses as required. Ensure that both old and new prescriptions are included for requests related to significant changes.
7. In the Fees section, provide the material and professional fees for the services requested.
8. Review all entered information to verify accuracy. Once complete, you can save changes, download, print, or share the form according to your needs.

Complete the Medically Necessary Contact Lens Prior Approval Form online today and ensure your request is submitted accurately.