Get Med 4 (08/25/2010) Customer Vision Report Purpose: Use This Form To Request Vision Examination

The MED 4 (08/25/2010) Customer Vision Report is designed to facilitate the request for vision examination information from your ophthalmologist or optometrist. This guide will walk you through each section of the form, ensuring you provide all necessary information accurately and efficiently.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. Begin by filling out the Customer Information section. Provide your last name, first name, middle initial, and suffix. Make sure to include your residence/home address along with the city, state, and zip code. Additionally, input your daytime telephone number and customer number (from your driver license) or Social Security Number.
3. Indicate if the provided address is new by checking the relevant box. Ensure that your birthdate is entered in the specified format (mm/dd/yyyy). If your mailing address differs from your home address, complete this section with the same level of detail.
4. Next, have your ophthalmologist or optometrist complete the Vision Examination section. They will need to fill in the dates for the first and most recent vision examinations to meet the requirement of being conducted within 90 days prior to your submission.
5. Your provider will assess and document the visual measurements, including uncorrected and best corrected visual acuity for both eyes, along with the horizontal visual field. Ensure all fields are completed accurately.
6. Verify if there are any ocular conditions that may affect your ability to drive safely. Your provider will indicate 'yes' or 'no' and specify the conditions if applicable.
7. Instruct your ophthalmologist or optometrist to provide their name, medical license number, and to check the relevant box indicating whether they are an ophthalmologist or optometrist. They should also complete their expiration date, telephone number, and business address.
8. Finally, your medical provider must sign and date the form, certifying the information provided is accurate. Ensure that all aspects of the form are complete.
9. Once all sections are filled out, save any changes made to the document. You may also download, print, or share the completed form as needed.

To proceed with your vision examination request, complete the MED 4 form online today.