Bout the option of impact resistant polycarbonate lenses. **Medicaid ID # (required or write N/A) JOB TYPE PATIENT LAST NAME Frame Only Lenses Only New Job Optician initial here: PATIENT FIRST NAME Contact Name and Phone Number SEG TYPE (circle) MATERIAL (circle) S/V - Single Vision Plastic FlatTop28 SPECIAL BC TOTAL PAID $ SPH CYL Progressive (requires Monocular PD) Polycarb (-5.25/+4.00) TYPE Hi Index (1.67) AXIS DIST PD NEAR Add Transitions Brown Grey Seg Height ADD .
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How to fill out the Atlanta Eye Custom Optical Laboratories Form online
This guide provides a comprehensive overview of how to complete the Atlanta Eye Custom Optical Laboratories Form online. By following the steps outlined below, users will find it straightforward to fill out each section accurately and efficiently.
Follow the steps to complete the online form.
- Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
- Input the date of service in the required field to ensure your submission is timely.
- Provide the Medicaid ID number in the specified section. If you do not have one, write 'N/A'.
- Indicate the job type by selecting one of the available options: Frame Only, Lenses Only, or New Job.
- Fill in the patient's last and first name, ensuring that all names are entered correctly.
- If applicable, include the contact name and phone number for further communication.
- Select the segment type and material by circling the appropriate answers for each.
- Complete the prescription details by providing the SPH, CYL, and AXIS measurements as necessary.
- Add information for any additional requirements, such as Transitions and specific treatments like UV400 Protection.
- Specify any special instructions or notes in the provided section to ensure all needs are met.
- Finally, review all the entered information to confirm accuracy, and then choose to save changes, download, print, or share the completed form.
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