BC's At Home Program uses this one-page request to fund prescription lenses and frames for an enrolled child when the glasses are needed because of the child's disability or specific medical diagnosis. Parents supply the optical supplier's quote and details of any extended health coverage. The physician or nurse practitioner records the diagnosis and the clinical justification.
The parent or guardian completes and signs Part 1 (child details, extended health coverage, optical supplier and quoted price). The physician or nurse practitioner completes and signs Part 2 with the medical diagnosis or disability and a clear justification for the lenses and frames.
Download the current version from the source each time; forms change without notice.
At Home Program Request for Optical Benefits
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
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Two people sign. The parent or guardian signs Part 1 after giving the child's details, extended health coverage and the optical supplier's quote. The physician or nurse practitioner signs Part 2 after recording the medical diagnosis or disability and explaining why lenses and frames are required because of it.
No. Optical funding is only for children enrolled in At Home Program Medical Benefits, and only for optical needs directly related to the child's disability or specific medical diagnosis. There is a funding limit per 12-month period, and the form asks whether the child has extended health benefits that include optical.