Home → VA Prosthetics → VA Handbook 1173.12 - Prescription Optics and Low-Vision Devices → Procuring Eyeglasses Using VA Forms 10-2914 and 10-2421
a. A written policy must be developed at each medical facility outlining procedures for procurement of prescription optics from a local licensed optometrist, ophthalmologist, or optician vendor for those beneficiaries authorized to use fee-basis optometrists or ophthalmologists (see the Eyeglasses Solicitation Template Guidelines on the Prosthetics Intranet Website: http://vaww.va.gov/prosthetics for guidance.
(1) Eyeglasses may be delivered to the optometry clinic, ophthalmology clinic, optical dispensary, Prosthetics and Sensory Aids Service, or beneficiary's home address when direct delivery is in the best interest of the beneficiary. Patient education materials on Care of Your Eyeglasses (App. A), and Bifocal Adaptation (App. B) need to accompany the delivery of eyeglasses, as appropriate to the recommended prescription optics.
(2) Verification that the spectacles match the appropriate prescription within applicable ANSI Z80 standards and tolerances must be conducted by the vendor prior to delivery of each pair of eyeglasses.
(3) The prosthetic activity or VA-owned optical laboratory must sample at least five pairs of prescription optics per month of the home delivery patients, and five pairs of prescription optics per month of those patients receiving prescription optics at the VA facility in order to ensure prescriptions were filled correctly within applicable ANSI Z80 standards and tolerances.
(a) Adherence to ANSI Z80 Standards will be determined by local community eyeglass providers (optician, optometrist, or ophthalmologist) through the "Voucher for Eyeglasses Adjustment and Analysis" template for home delivery patients (see par. 16).
(b) For prescription optics dispensed at the local VA facility, the optometry clinic and/or ophthalmology clinic, as appropriate, is responsible for an ongoing quality assurance verification program in concert with the local VA prosthetic activity.
(4) The facility needs to maintain one copy of either VA Form 10-2421 (ADP) or VA Form 10- 2914 in a pending order file until delivery is completed.
(5) After completion, one copy of the VA Form 10-2421, or the VA Form 10-2914 and the shipping document must be filed in the beneficiary's Consolidated Health Record (CHR) i.e., the patient's medical paper file at the local facility.. NOTE: Attach the invoice to the copy of the 10- 2421 or the 10-2914.
b. Local policy must be developed to verify receipt of eyeglasses and payment procedures using the appropriate ADP or VA forms.
c. In the event eyeglasses are not within tolerance, the local prosthetic activity returns them to the vendor for correction. While this may result in eventual receipt of two pairs of eyeglasses, this is acceptable under the circumstances.
d. Upon receipt of a bill or invoice, the local prosthetic activity must verify that amounts are correct and certify appropriate documents for payme