VA Form 10-2914 Prescription and Authorization for Glasses

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 FEE BASIS 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.
PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, U.S.C., Veterans Benefits, and will be used to determine your eligibility/entitlement and reimbursement of
individual claims, and identify your medical records. Additional information may be solicited during the course of processing your application. The information you supply may also be disclosed outside the VA as permitted by law
or as stated in the "Notices of Systems of VA Records" 24VA136, published in the Federal Register. Disclosure is voluntary, however, failure to furnish the information will result in our inability to process your request promptly
and serve your medical needs. Failure to furnish the information will have no adverse effect on any other benefits to which you may 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. LAST 4 DIGITS OF SSN (mandatory)

NEAR

DISTANCE

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

3A. SPHERE

3B. CYLINDER

3C. AXIS

3D. PRISM

3E. BASE

3F. BC

5A. ADDITION

5B. HEIGHT

5C. TYPE

5D. WIDTH

5E. NEAR INSET

5F. TOTAL INSET

4. MEDICAL JUSTIFICATION*

3G. MRP

L
R

5G. PD
FAR
NEAR

L

6A. FRAME NAME

6B. COLOR

6C. MANUFACTURER

6D. EYESIZE

6E. BRIDGE SIZE

6F. TEMPLE LENGTH & STYLE

7. ICD-9 CODE

12. DELIVERY RECOMMENDATION

8A. LENSES ONLY

9A. GLASS

10A. SINGLE VISION

11A. TINT*

8B. USE ENCLOSED FRAMES

9B. PLASTIC LENSES

10B. BIFOCAL

11B. TRANSITIONS*

12A. VETERAN'S RESIDENCE

8C. FRAME ONLY

9C. SAFETY LENSES

10C. TRIFOCAL

11C. PROGRESSIVE*

12B. EYE CLINIC
12C. PROSTHETICS

11D. OTHER*
13. SIGNATURE AND DEGREE OF EXAMINER

14. DATE OF EXAMINATION
(mm/dd/yyyy)

M.D./O.D.

PART III - TO BE FULLY COMPLETED BY THE PROSTHETIC ACTIVITY OR PROSTHETIC CLERK
15A. CONTRACTOR

15B. CONTRACT NUMBER

19. CONTRACT INFORMATION

TO

ITEM

CONTRACT ITEM

COST

RIGHT LENS

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

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

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

OTHER
CASE
TOTAL COST
20. INSTRUCTIONS TO CONTRACTOR - MAIL TO:
ORDERING FACILITY - EYE CLINIC

VETERAN AT ABOVE
ADDRESS

ORDERING FACILITY - PROSTHETIC

21. SIGNATURE AND TITLE OF APPROVING OFFICIAL
18. ELIGIBILITY STATUS

SC

NSC

PART IV - TO BE COMPLETED BY CONTRACTOR
22. COMMENTS:

23. THE GLASSES AUTHORIZED HAVE BEEN MAILED TO:
THE PATIENT AT THE ABOVE ADDRESS
V.A. EYE CLINIC DELIVERY POINT
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

VA FORM
JUN 2008

10-2914

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

28. DATE (mm/dd/yyyy)