Prior Authorization Vision Services Attachment Page 2
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2PRIOR AUTHORIZATION / VISION SERVICES ATTACHMENT (PA/VA)
Page 2 of 2
F-11051 (07/12)
SECTION III — DOCUMENTATION (Continued)
9.
Tints (All requests for tints must include specific documentation of visual or medical necessity from the prescribing provider. A
diagnosis of photophobia, without substantiation, is insufficient justification.)
Rose 1
Rose 2
Photochromic
Other tint (explain)
Justification for tint (see above)
10. Other Vision Services Requested (Include a description of services requested, pertinent history / findings, and justification.)
11. SIGNATURE — Requesting / Rendering Provider
12. Date Signed
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