Medicaid Eyeglass Breakage and Loss Form

Form Template

The Medicaid Eyeglass Breakage and Loss Form is a simple but essential app which can be used by any optometrist, eye care or eye examinations facility to report the details of eyeglasses which are brought in damaged, broken, lost, or stolen.

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The form is detailed for those eligible for Medicaid but could be utilized for any health plan or just basic optometry services. For eyeglasses that have been lost or stolen, the form limits such claims to a children's health insurance program. The form is broken down to report damage to the eyeglasses frame, or one/both of the eyeglass lenses. Providing vision services to those with Medicaid coverage is essential for continued eye health, as are frequent eye examinations, to prevent further health issues like vision loss and age-related macular degeneration, and other diseases that would require eyeglasses under the Medicaid program. Using this app to record repairs and replacements for patients with Medicaid coverage will improve the efficiency of any optometrist and is quick and easy to use, as well as fully customizable.

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