Medical Eye Care Services Program Manual
Table of Contents

PREFACE

ABBREVIATIONS/ACRONYMS/FORM TITLES

DEFINITIONS

SECTION 100: MEDICAL EYE CARE PROGRAM POLICY

I. PHILOSOPHY

II. LEGAL BASE

III. DESCRIPTION OF MEDICAL/EYE CARE SERVICES

IV. REQUEST FOR A CONFERENCE

SECTION 200: ELIGIBILITY CRITERIA AND APPLICATION PROCESS

I. PROGRAM ELIGIBILITY

II. INSTRUCTIONS FOR COMPLETING DSB-2001: APPLICATION FOR EYE CARE CERTIFICATION

III. EYE EXAMINATIONS AND REFRACTIONS

IV. RETROACTIVE AUTHORIZATION FOR EYE EXAMINATIONS AND EMERGENCY SURGERY/HOSPITALIZATION

V. REDETERMINATION OF ELIGIBILITY

SECTION 300: SPECIAL SERVICES

I. EYE SURGERY GUIDELINES

II. AUTHORIZING DRUGS FOR INDIVIDUAL RECIPIENTS

III. CONTACT LENSES

SECTION 400 PART A: FORMS AND APPLICATION PROCESS

DSB-2001 APPLICATION FOR EYE CARE CERTIFICATION

DSB-2031 LETTER TO ACCOMPANY MAILED APPLICATION

DSB-2032 NOTIFICATION OF NEED FOR ADDITIONAL INFORMATION

DSB-2033 NOTIFICATION OF ELIGIBILITY STATUS

DSB-2202 REPORT OF EYE EXAMINATION

DSB-7219 APPLICATION FOR CONFERENCE

SECTION 400 PART B: FORMS FOR SCREENINGS

DSB-2007: EVALUATION WITH VIDEO MAGNIFICATION (CLOSED CIRCUIT TELEVISION)

DSB-2207 VISION SCREENING LIST

DSB-2218 PERMISSION FORM FOR VISION SCREENING AT DAY CARE

DSB-2220 REPORT TO PARENTS OF CHILD SCREENED AT DAY CARE

DSB-2205-A REFERRAL FOR LOW VISION SCREENING

DSB-2205-B REPORT ON LOW VISION EVALUATION

SECTION 400 PART C: FOR BILLING FORMS

DSB-4020 PHARMACY AGREEMENT

DSB-0511 PHARMACY BILLING FORM

HCFA-1500: INSTRUCTIONS FOR COMPLETING THE HCFA-1500 CLAIM FORM

DSB-0950 VERIFICATION OF ITEMS RECEIVED

APPENDIX A: DIRECTORY OF NURSING EYE CARE CONSULTANTS AND OFFICES

APPENDIX B: MEDICAL EYE CARE AUTOMATION

APPENDIX C: AUTHORIZATION TO DISCLOSE HEALTH INFORMATION

APPENDIX D: DESK REFERENCE FOR MEDICAL EYE CARE PROGRAM

APPENDIX E: COUNTY CODES

APPENDIX F: VOTER REGISTRATION

For questions or clarification on any of the policy contained in these manuals, please contact the local district office.