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)*

Date of Birth: *

Patient Name: *

Phone Number: *

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: *