Stolen, Broken or Damaged Glasses

Replacement material may be covered for Medi-Cal members for reasons other than loss, theft, or destruction in circumstances beyond the recipient's control. Pre-authorization is required. The member must explain the circumstances of the replacement and the reason the existing frame cannot be used.

Patient Information


Insurance (select one)*
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Date of Birth: *
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Patient Name: *
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Phone Number: *
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Would you like to request a new eye exam? (Please Explain)*


Explain how your frame, lens, or glasses were broken, damaged, or lost. If the glasses were lost, did you try to find them? (Please Explain)*


Patient/Guardian Signature:*


​​​​​​​Date: *

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