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Use this form to claim a refund for an NHS sight test, glasses or contact lenses if you are entitled to help due to your income.

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Part of:
First published:
22 September 2020
Last updated:

Documents

HC5W(O) Claim form for a refund of optical charges
, file type: PDF, file size: 122 KB

PDF
122 KB
If you need a more accessible version of this document please email digital@gov.wales. Please tell us the format you need. If you use assistive technology please tell us what this is.

Details

Use this form to claim back the cost of:

  • a sight test
  • glasses
  • contact lenses

For glasses and contact lenses, the maximum refund anyone can have is the voucher value that matches their prescription.

You may also have to submit an HC1W claim form (see part 4).

If you paid for a repair or replacement because your glasses/contact lenses were lost or damaged, your local health board has to agree that the loss or damage was because of illness before you can get a refund. Send a note with this form to tell us how the loss or damage happened.

If you wish to claim a refund of glasses or contact lenses, for a reason other than because you have a low income, please send your receipts and optical prescription to your local health board.

You can request a printed copy of this form via email or by calling the publications order line on 0345 603 1108.

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