MIC OPTICAL Ordering Form

CONTACT INFORMATION

First Name:

Last Name:

Mailing Address

City:

State:

Zip Code:

Phone:

Email Address:

Medicaid Number*

Date of Exam*

Must be under 2 years from date of service in accordance with AK guidelines

Eyeglass rx

Rows	Sphere	Cylinder	Prism	Add
OD (R)
OS (L)

Measurements

Rows	Distance PD	NEAR PD.
OD
OS

I have a current eyeglass prescription would like to be contacted to help me get a copyI don't have a current exam and would like to be contacted to make an appointment

Frame information (please refer to catalog link at the bottom of the form)

Rows	Frame Name	Eye size	Color
Frame

Lenses Type

CR-39PolycarbonateLined Bifocal (FT 28)Single Vision

NOTES

Additional comments or questions:

Signature