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Unum CL-1193 Non-Elective Contact Lenses Request Form

Members of Unum group vision plans need this 1-page request when contact lenses are medically necessary rather than elective. The optometrist or ophthalmologist identifies the member and provider, checks one qualifying condition, adds notes and signs. The vision plans are marketed by Unum and administered and underwritten by Starmount Life Insurance Company.

Who completes it

The eye care provider completes the whole page: member information, provider information with Tax ID or NPI, the qualifying condition, notes and the provider signature.

Submitting and payment

How to submit it
Return the completed form to Unum vision claims by fax, email or mail, using the contacts printed at the bottom of the form.
Who pays
The form lists no fee or billing code; it requests coverage of the lenses, not payment for completing the form.

Good to know

  • Qualifying conditions include aphakia after cataract surgery, anisometropia of 4.0 diopters or more with acuity improving to 20/60 or better, and keratoconus.
  • Another option covers vision that cannot be corrected to 20/70 in the better eye except with contact lenses, which must then reach 20/60 or better.
  • Other optical conditions, such as corneal disease or scarring, qualify if contacts improve best corrected acuity by two Snellen lines over spectacles; documentation is required.
  • For aphakia, a pair of single-vision or multifocal lenses and frames can be provided along with the contact lenses.

Get the official form

Download the current version from the source each time; forms change without notice.

Non-Elective Contact Lenses Request Form

Official pagePDF

Fill it with Vero

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.

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How this list is checked

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 and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Which conditions qualify for non-elective contact lenses under Unum vision plans?

The form lists aphakia, anisometropia of 4.0 diopters or more, keratoconus, vision not correctable to 20/70 in the better eye except with contacts, and other optical conditions where contacts markedly improve best corrected acuity, such as corneal disease or scarring after accident or surgery.

Who signs the Unum non-elective contact lens form?

The eye care provider signs, prints their name and dates the form, and gives a Tax ID or NPI number, phone, primary contact and email. The member section records name, date of birth, member ID, group number and employer.

What form number is printed on the Unum contact lens request?

The footer prints CL-1193-3 (11-21). Unum's forms library also titles it the Medically Necessary Contact Lenses Request form. It is a group vision plan form, separate from Unum's disability and life claim forms.