NC Medicaid uses DMA372-017A to request prior approval for visual aids beyond standard coverage, such as complete glasses, exceptional services or contact lenses. Optometrists and ophthalmologists meet it after a refraction when a beneficiary needs one of these items. The form records frame and lens details, the full prescription and contact lens information, and goes to NC Medicaid for review.
The optometrist or ophthalmologist completes recipient, diagnosis, provider, service, frame, lens, prescription and contact lens information, adds any instructions for the Medicaid contractor laboratory, and signs as requesting provider.
Download the current version from the source each time; forms change without notice.
Visual Aid Request for Prior Approval
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 and their requirements change without notice, so check the official page for the current version before you complete one.
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When an optometrist or ophthalmologist requests NC Medicaid prior approval for eyeglasses or other visual aids beyond standard coverage, including exceptional services and contact lenses. NCTracks lists it among the prior approval request forms that can be mailed or faxed.
The prescription section has right and left rows for sphere, cylinder, axis, prism, base, add, segment height, distance and near pupillary distance, and Fresnel base, plus lens circumference and options such as slab-off and an ultraviolet filter.