Contact Lens Order Form
DEMOGRAPHICS INFORMATION
Date of Service
Optician
Carolyn
Diego
Mariah
Mike
Rose
Stephanie
Provider
MAE
RWL
ATS
PKW
Patient Phone
Patient Name
Date of Birth
*Note:
DX = Diagnostic or Trial Lenses
OD
OS
OU
For Stock
Manufacturer & Brand of Contact
Manufacturer & Brand of Contact
Box or Qty
Price Each
Total
Base Curve
Sphere
Cylinder
Axis
Add
Diameter
Color
V-Code
Diagnosis
↓
COPY
↑
OS
OD
OU
For Stock
Manufacturer & Brand of Contact
Manufacturer & Brand of Contact
Box or Qty
Price Each
Total
Base Curve
Sphere
Cylinder
Axis
Add
Diameter
Color
V-Code
Diagnosis
Show Section 2
INSURANCE INFORMATION
Insurance
VSP
Eyemed
Spectera
Superior Vision
Providence
Blue Cross / Blue Shield
United Health Care
Medicare
Atrio
Regence
Health Net
Cigna
Pacific Source
Regence Med Advantage
Regence BCBS
AARP
WVCH
DMAP
Moda
Providence PEBB
Tricare
Kaiser Choice
Ameritas
Employee Benefit Management Services (EBMS)
--OPTION NOT IN LIST--
Auth #
Insurance Benefit
Fitting Fee
%
$
Fee Discount
Total Fee
Show Fitting Section
Total Before Insurance
Patient Cost
Patient Paid
Patient Paid In Full
Check @ Dispense
Notes
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