Form 10-2914 PRESCRIPTION AND AUTHORIZATION FOR EYEGLASSES

OMB Number: 2900-0188
Estimated Burden: 4 minutes

NOTE: Instructions are written for a multi-part form. Print additional copies as necessary.

PRESCRIPTION AND AUTHORIZATION FOR EYEGLASSES
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not
required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all providers who must complete this
form will average 4 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to allow veterans to
purchase their eyeglasses directly by serving as a prescription, authorization and invoice. Although you must submit a bill to receive reimbursement, return of this form is
voluntary. Failure to respond will have no adverse effect on benefits to which the provider might otherwise be entitled.

PART I - TO BE COMPLETED BY EXAMINING EYE CLINIC (PLEASE PRINT OR TYPE LEGIBLY)

1. VETERAN'S NAME (Last, first, middle initial) (mandatory)

3. SOCIAL SECURITY NUMBER (If known) (mandatory)

2. CLAIM NUMBER (If known)

C-

NEAR

DISTANCE

PART II - TO BE FULLY COMPLETED BY EXAMINING OPHTHALMOLOGIST OR OPTOMETRIST
R

4A. SPHERE

4B. CYLINDER

4C. AXIS

4D. PRISM

4E. BASE

4F. BC

4G. MRP

5A. ADDITION

5B. HEIGHT

5C. TYPE

5D. WIDTH

5E.
NEAR INSET

5F.
TOTAL INSET

5G. PD

*SPECIAL INSTRUCTIONS

L
R

FAR
NEAR

L
6A. FRAME NAME

6B. COLOR

6C. MANUFACTURER

6D. EYESIZE

6E. BRIDGE SIZE

6F. TEMPLE LENGTH & STYLE

7A. LENSES ONLY

8A. GLASS

9A. SINGLE VISION

10A. SUPPLY CASE

7B. USE ENCLOSED FRAMES

8B. PLASTIC LENSES

9B. BIFOCAL

10B. TINT*

7C. FRAME ONLY

8C. SAFETY LENSES

9C. TRIFOCAL

10C. OTHER*

11. DELIVERY RECOMMENDATION
11A. VETERAN'S RESIDENCE
11B. EYE CLINIC
11C. PROSTHETICS
13. DATE OF EXAMINATION
(mm/dd/yyyy)

12. SIGNATURE AND DEGREE OF EXAMINER
M.D./O.D.

PART III - TO BE FULLY COMPLETED BY THE PROSTHETIC ACTIVITY OR PROSTHETIC CLERK

TO

14A. CONTRACTOR

14B. CONTRACT NUMBER

15. VETERAN'S ADDRESS (Type name if unclear above)

16. ORDERING VA MEDICAL CENTER (Name, Address, Symbol)

18. ELIGIBILITY STATUS (Check all appropriate boxes)
17. AUTHORITY FOR ISSUANCE
V.A. 6115 ____ (Charge Medical Care Appropriation)
VA 6115.3 (Charge appropriation 36X0102, account 3403)
OTHER
19. CONTRACT INFORMATION

ITEM

CONTRACT ITEM

COST

SC

OP

50%

NSC

VNE

RET. MIL.

IP

A and A

INITIAL

DISABILITY
CODE

SC

NSC

PART IV - TO BE COMPLETED BY CONTRACTOR

22. COMMENTS:

RIGHT LENS
LEFT LENS
LENS TINT
FRAME COMPLETE
FRAME FRONT ONLY
FRAME TEMPLE RIGHT
FRAME TEMPLE LEFT
OTHER

THE PATIENT AT THE ABOVE ADDRESS

CASE

V.A. EYE CLINIC DELIVERY POINT
TOTAL COST

20. INSTRUCTIONS TO CONTRACTOR - MAIL TO:
VETERAN AT ABOVE
ORDERING FACILITY - EYE CLINIC
ADDRESS
ORDERING FACILITY - PROSTHETIC
21. SIGNATURE AND TITLE OF APPROVING OFFICIAL

VA FORM
FEB 2005 (R)

23. THE GLASSES AUTHORIZED HAVE BEEN MAILED TO:

10-2914

V.A. PROSTHETICS DELIVERY POINT
24. OBLIGATION SYMBOL (order
will be rejected unless completed)

25. ORDER DATE
(mm/dd/yyyy)

27. SIGNATURE OF COMPANY OFFICIAL

26. ESTIMATED DELIVERY
DATE (mm/dd/yyyy)

28. DATE (mm/dd/yyyy)

OMB Number: 2900-0188
Estimated Burden: 4 minutes

PRESCRIPTION AND AUTHORIZATION FOR EYEGLASSES
This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not
required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all providers who must complete this
form will average 4 minutes. This includes the time to read instructions, gather the necessary facts and fill out the form. The purpose of this form is to allow veterans to
purchase their eyeglasses directly by serving as a prescription, authorization and invoice. Although you must submit a bill to receive reimbursement, return of this form
is voluntary. Failure to respond will have no adverse effect on benefits to which the provider might otherwise be entitled.

PART I - TO BE COMPLETED BY EXAMINING EYE CLINIC (PLEASE PRINT OR TYPE LEGIBLY)

1. VETERAN'S NAME (Last, first, middle initial) (mandatory)

2. CLAIM NUMBER (If known)

3. SOCIAL SECURITY NUMBER (If known) (mandatory)

C-

NEAR

DISTANCE

PART II - TO BE FULLY COMPLETED BY EXAMINING OPHTHALMOLOGIST OR OPTOMETRIST

4A. SPHERE

4B. CYLINDER

4C. AXIS

4D. PRISM

4E. BASE

4F. BC

4G. MRP

5A. ADDITION

5B. HEIGHT

5C. TYPE

5D. WIDTH

5E.
NEAR INSET

5F.
TOTAL INSET

5G. PD

*SPECIAL INSTRUCTIONS

R
L
R

FAR
L

NEAR

6A. FRAME NAME

6B. COLOR

6C. MANUFACTURER

6D. EYESIZE

6E. BRIDGE SIZE

6F. TEMPLE LENGTH & STYLE

7A. LENSES ONLY

8A. GLASS

9A. SINGLE VISION

10A. SUPPLY CASE

7B. USE ENCLOSED FRAMES

8B. PLASTIC LENSES

9B. BIFOCAL

10B. TINT*

7C. FRAME ONLY

8C. SAFETY LENSES

9C. TRIFOCAL

10C. OTHER*

12. SIGNATURE AND DEGREE OF EXAMINER
M.D./O.D.
VA FORM
FEB 2005 (R)

10-2914

11. DELIVERY RECOMMENDATION
11A. VETERAN'S RESIDENCE
11B. EYE CLINIC
11C. PROSTHETICS
13. DATE OF EXAMINATION
(mm/dd/yyyy)