Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to acquire the form and launch it in your preferred editor.
2. Begin by entering the patient’s name at the top of the form. This is a crucial field that identifies the individual for whom the order is being placed.
3. Next, input the date of service and the date of birth of the patient. These dates help in tracking and confirming the order details.
4. Fill in the sphere, cylinder, axis, and prism measurements. Ensure accuracy as these values are vital for creating the prescription lenses.
5. Provide the Medicaid member ID number. This verifies the patient's insurance eligibility.
6. Complete the sections regarding thickness, edge, and center specifications for lenses, ensuring that all details align with the patient's requirements.
7. Indicate whether the order is medically necessary and specify the lens material, such as polycarbonate.
8. Address the frame details by selecting the frame type and providing related information such as size, bridge, and style.
9. If applicable, note any replacements under warranty and specify if the frame name and/or shape is included.
10. Fill out the customer’s name and address, along with the NPI provider number for verification purposes.
11. Once all sections are completed, review the filled form for accuracy. Save the changes, and then download, print, or share the document as necessary.

Complete all required documents online to ensure a seamless application process.