Contact Lense Prescription Form PDF Details

Fulfilling a need for vision correction, the Illinois Department of Healthcare and Family Services presents a structured approach through its Optical Prescription Order form, ensuring detailed information from healthcare providers is captured efficiently. This document, pivotal for accurately dispensing corrective lenses, demands comprehensive data ranging from provider details, patient identification, to intricate specifications of the prescribed contact lenses. It highlights the provider's name and National Provider Identifier (NPI), alongside the date of service (DOS) and contact information, ensuring a clear linkage between the prescription and the medical professional. The form delves into the heart of optical correction by detailing patient-specific requirements such as power, prism, pupillary distance, and base curve for both eyes, thereby tailoring the prescription to individual needs. Further, it accommodates choices in lens and frame materials, with options like glass, plastic, and polycarbonate, and frames made from plastic or metal, considering the wearer's comfort and lifestyle. Notable also is the call for a signature from the provider, a testament to the accuracy and completeness of the information provided, underscoring the commitment to comply with state and federal guidelines in healthcare provision. This document, therefore, not only facilitates the precise creation and dispensing of eyewear but also adheres to regulatory standards aimed at protecting patient welfare in the realm of vision care.

QuestionAnswer
Form NameContact Lense Prescription Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namescontact lens prescription pdf, contact lense prescription, blank contact lens prescription form, blank contact prescription form

Form Preview Example

Illinois Department of

 

 

 

 

 

 

Healthcare and Family Services

 

 

 

 

 

 

OPTICAL PRESCRIPTION ORDER

 

 

Document Control Number

1. PROVIDER NAME

 

2. NPI

 

 

3. DOS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. CITY

 

STATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. RECIPIENT NAME (FIRST, MI, LAST)

 

 

 

 

 

 

 

7. RECIPIENT NO.

 

 

 

 

8. BIRTHDATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POWER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRISM

 

 

 

 

 

 

 

 

 

 

 

DPD

 

NPD

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPHERE CYLINDER

 

AXIS

 

IN

 

 

 

OUT

UP

DOWN O.C. HEIGHT

 

 

 

 

 

SEGMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDITIONAL INFORMATION

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADD HEIGHT BASE CURVE

DEC

INSET TOTAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENS MATERIAL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

L

LENS STYLE

check one:

Glass

Plastic

Polycarbonate

FRAME MATERIAL (CHECK ONE): PLASTIC

METAL

 

FRAME NAME

 

 

 

 

 

FRONT/CHASSIS COLOR

 

 

 

 

 

 

 

 

 

 

 

 

 

MFG.

EYE

 

 

DBL

 

 

TPL SIZE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

My signature certifies that all entries on this document are true, accurate and complete; records necessary to fully disclose the nature and extent of services provided are maintained and will be made available upon request of State and Federal officials (responsible for the various aspects of the State's Medical Assistance Program, as provided under Title XIX and Title XXI of the Social Security Act and applicable State statutes); and eyeglasses and/or parts will be dispensed to this recipient within a reasonable time period after receipt from the Department of Corrections.

Signature

Signature Date

HFS 2803 (R-5-08)

IL478-1530

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The PDF file you plan to complete will consist of the following segments:

filling out blank contact prescription form step 1

Provide the required details in the SEGMENT, ADDITIONAL INFORMATION, ADD, HEIGHT, BASE CURVE DEC, INSET, TOTAL, LENS MATERIAL, check one, Glass, Plastic, Polycarbonate, LENS STYLE, FRAME MATERIAL CHECK ONE, and PLASTIC box.

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