Prices
VSP
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FRAME CALCULATION BOX
WFA
Frame Retail
Frame Benefit
Discount
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Material Copay
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DEMOGRAPHICS
Optician:
Mariah
Mike
Rose
Stephanie
Date:
Doctor:
MAE
RWL
ATS
PKW
Patient Name:
Birthdate:
DOES THE PATIENT HAVE INSURANCE?
Yes
No
INSURANCE ON FILE
VSP SIGNATURE
VSP CHOICE
VSP ADVANTAGE
SPECTERA
EYEMED
SUPERIOR VISION
Auth #
AETNA
AMERITAS
ATRIO - SPECIAL NEEDS
BLUE CROSS BLUE SHIELD
CIGNA
EBMS
MEDICARE OF OREGON
MESO
MODA
PACIFICSOURCE
PROVIDENCE
INSURANCE NOT LISTED
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FRAME INFORMATION
New Frame
Patients' Own Frame
Flexsys #:
Frame Enclosed
Frame On Order
Frame Drop Shipped
Patients' Frame Enclosed
Lenses Only w/ Trace
Reference
U & C
OOP
Manufacturer
Line
or
Collection
Model
Color
Eye
B
ED
Bridge
Temple
Frame Type
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Advantage Package Section
HOYA ADVANTAGE PACKAGE W/ TRIVEX
SINGLE VISION $140
ST28 $170
7 X 28 - POLY ONLY $190
PROGRESSIVE $250
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SINGLE VISION
DISTANCE SV $130
COMPUTER SV $130
READING SV $130
MYSV $180
SYNCIII 500 $180
SYNCIII 750 $180
SYNCIII 1000 $180
SYNCIII 1250 $180
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OOP
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BIFOCAL
ST28 $170
ST35 $260
EXECUTIVE $230
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TRIFOCAL
7 X 28 $190
8 X 35 $280
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PROGRESSIVE
MYSTYLE 2 $420
ARRAY 2 $340
CD / ECP BKS $250
ZOOM $250
SCREEN $250
SPACE $250
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MATERIAL
PLASTIC
POLY $90
TRIVEX $90
HI-INDEX 1.60 $140
HI-INDEX 1.67 $140
HI-INDEX 1.70 $140
HI-INDEX 1.74 $140
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ANTI-REFLECTIVE
EX4 $170
EX3+ $170
RECHARGE $150
EX3 $150
PREMIUM W/ VIEW PROTECT $150
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PHOTOCHROMIC
GREY $150
FAST GREY $150
DARK GREY $150
BROWN $150
FAST BROWN $150
DARK BROWN $150
BLUE $150
GREEN $150
DARK GREEN $150
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POLARIZED
GREY $150
BROWN $150
GREEN $150
COPPERTONE GREY $150
COPPERTONE BROWN $150
COPPERTONE GREEN $150
G15 $150
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MIRROR
SILVER $80
WHITE $80
RED $80
GREEN $80
BLUE $80
BRONZE $80
GOLD $80
ROSE $80
STRONG BLUE $80
FLASH WHITE $80
FLASH AMBER $80
FLASH JADE $80
SAPPHIRE $80
RUBY $80
COOL BLUE $80
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TINT
GREY $40
BROWN $40
PIONEER $40
BLUE $40
ROSE $40
MATCH TINT $40
CUSTOM $40
SOLID
GRADIENT
%
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OTHER
CLARITY SHIELD 2 $40
FACTORY SCRATCH COAT $22
EDGE POLISH $20
BLUEGUARD $20
OVERSIZE (EYE 61+) $24
DRILLED RIMLESS $30
SEMI-RIMLESS $0
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MEASUREMENTS
PDS:
Seg Ht:
POW:
TOTALS
NOTES
COPAY
SUBTOTAL
BENEFIT
DISCOUNT
TOTAL
%
%
Patient Pays in Full
Patient to Pay 1/2 on Pickup
PAID TODAY
OWES @ PICKUP
DEMOGRAPHICS
INSURANCES
FRAMES
INSURANCES
LENS STYLES
MATERIALS
ANTIGLARE
PHOTOCHROMIC
POLARIZED
MIRROR
TINTS
OTHER
FINANCIALS
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