VISION SERVICES APPROVAL / ORDER
Please provide us with your email address :

NOTE: Approval refers to services and does NOT guarantee beneficiary eligibility.
Anything in red is a required field.
1. Prior Authorization Number
2
3
4
5
6
 
7. Provider Name (Last, First, Middle Initial)
8. Address (No. & Street, Suite, Lot, etc.)
City State ZIP Code
9. Phone No 10. Provider ID Number
11. Provider Signature 12. Date of Order
  13. Provider Type
14. Beneficiary Name (Last, First, Middle Initial)
15. Address (No. & Street, Apt. No., etc)
CIty State ZIP Code
16. Sex
17. Birth Date 18. Beneficiary ID Number
19. Diagnosis:
  20. DESCRIPTION OF SERVICE(S) R L 21. PROC. CODE 22. QUANTITY 23. CHARGE
01
02
03
04
05
06
07
24. Reason:
INITIAL GLASSES REPLACEMENT DIOPTER CHANGE        
25. Lens Type
PLASTIC GLASS POLYCARBONATE LENS(ES) ONLY FRAME ONLY
26. Lens Style:
SINGLE VISION BIFOCAL TRIFOCAL HI INDEX CATARACT
27. Frame Name Manufacturer
 
Color Eye Size Bridge Temple Style & Length
LENS SPECIFICATIONS
28.
SPHERE
CYLINDER
AXIS
PRISM POWER &
BASE DIRECTION
MRP
HORIZONTAL
HEIGHT
R
L
 
ADD
SEGMENT HEIGHT
WIDTH & STYLR
SEGMENT INSET
TOTAL INSET
PD
R
L
29. Special instructions to Laboratory:
PREVIOUS LENS SPECIFICATIONS
30.
SPHERE
CYLINDER
AXIS
ADD
PRISM / DIRECTION
LENS STYLE
R
L