Medicaid Eyewear Order Form

Medicaid Eyewear Order Form
Please complete the Medicaid Eyewear Order Form to request eyewear under Medicaid coverage.
Patient Full Name
First NameLast Name
Patient Date of Birth
MonthDayYear
Date
Patient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Email Address
example@example.com
Provider Name or Clinic
Prescription Details
Eyewear Selection
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Standard Frames
Basic Medicaid-covered frames.
Free

Premium Frames
Upgraded frames with additional features.
$40.00

Single Vision Lenses
Standard single vision lenses.
Free

Bifocal Lenses
Lenses with two optical powers.
$25.00

Lens Coating
Anti-reflective or scratch-resistant coating.
$15.00

Total
$0.00
Shipping Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Order Date
MonthDayYear
Date
Last 4 Digits of Payment Card (if applicable)
Additional Notes or Order Comments
Should be Empty: