Non Insured Health Benefits (NIHB) Eye and Vision Products and Services Prior Approval and Claims Form

May 2005

Part 1 - Client Information

Surname:
Given Name(s):
Address:
Apt:
City:
Province:
Postal Code:
Area Code:
Telephone:
D.O.B.: DD MM YY
Client ID No.:
Band No.:
Family No:

Part 2 - Client Injury History

Is request due to an injury? Yes | No

If yes, w here d id the injury occur: Home | Work | Other

If other, please specify:

Date of injury: DD MM YY

Are these expenses eligible under another plan or program? Yes | No

If yes, please specify:

Claim No.:

Part 3 - Provider Information (Please use office stamp if available)

Provider No:

Area Code: Telephone:

Provider Signature:

Part 4 - Optical Information/Prescription

Oculo-visual Measure

• Right
  • Sphere
  • Cyl
  • Axis
  • Prism
  • Base
  • Add
• Left
  • Sphere
  • Cyl
  • Axis
  • Prism
  • Base
  • Add

Diagnosis & Other Relevant Information:

Benefits requested: (please complete information as is applicable in the region where benefit is accessed, for each product or service)

Benefit Description, Items

• Initial Request ( )
• Replacement ( )
• Acquisition cost
• Mark-up in $
• Total Cost
• MFR Product Name
• Product Number
• Warranty: Yes | No

Eye and vision exams (ONLY in regions where applicable)

Eye/vision exam, general (full, major, routine)

• Initial Request ( )
• Replacement ( )
• Acquisition cost
• Mark-up in $
• Total Cost
• MFR Product Name
• Product Number
• Warranty: Yes | No

Dispensing fees (ONLY in regions where applicable)

Fame dispensing fee, existing frame
Frame dispensing fee, new Laboratory fee
Lenses dispensing fee, bifocal
Lenses dispensing fee, unifocal
Delivery (remote areas, mailing & registration)

• Initial Request ( )
• Replacement ( )
• Acquisition cost
• Mark-up in $
• Total Cost
• MFR Product Name
• Product Number
• Warranty: Yes | No

Frames & frame repairs

Regular
Frame repairs, major
Frame repairs, minor
Lenses, opthalmic
Aspheric lens, left
Aspheric lens, right
Bifocal lens, left
Bifocal lens, right
High index, left
High index, right
Unifocal (Crown glass or plastic CR-39)
Other

• Initial Request ( )
• Replacement ( )
• Acquisition cost
• Mark-up in $
• Total Cost
• MFR Product Name
• Product Number
• Warranty: Yes | No

Part 5 - Client Signature

Client: I have received the above item(s) or service(s).

Signature of Client:
Parent or guardian:
Relationship to Patient if Guardian:
Date: (DD MM YY)

Part 6 - For NIHB Office Use Only

À remplir par le gestionnaire des SSNA :

PA Approval Number
Date:
Authorizing Officer: