Commonwealth of Massachusetts 

Executive Office of Health and Human Services 

Office of Medicaid 

600 Washington Street 

Boston, MA 02111 

www.mass.gov/masshealth 

 MassHealth 

 Vision Care Bulletin 15 

 May 2009 

 
 TO: Vision Care Providers Participating in MassHealth 

FROM: Tom Dehner, Medicaid Director 
 RE: New Vision Care Materials Order Form (VIS-1) 

Background In preparation for NewMMIS, MassHealth has updated its Vision Care 
Materials Order Form (VIS-1). Beginning May 26, 2009, providers must 
begin using the updated VIS-1 form when submitting vision care material 
order requests. 

New Format The VIS-1 Form has been edited to conform to the new 12-digit member 
and 10-digit provider identification numbers introduced as part of 
NewMMIS. To simplify the vision care form ordering process, the VIS-1 
form will no longer be printed on noncarbon reproduction paper. 
Beginning May 26, 2009, providers can simply copy the attached VIS-1 
form or download a copy from the MassHealth Web site at 
www.mass.gov/masshealth by clicking on the link titled Information for 
MassHealth Providers, then MassHealth Provider Forms. This new format 
also allows providers to directly enter data into certain fields before 
printing the form off of the MassHealth Web site. Providers must 
remember to maintain a copy of their completed VIS-1 Form requests for 
their own records before mailing the original completed forms to 
MassCor/Massachusetts Correctional Industries (mailing address 
appears on the form). 
 

Questions and Requests If you have any questions about the information in this bulletin, or would 
like to order copies of the VIS-1 form, please contact MassHealth 
Customer Service at 1-800-841-2900, e-mail your inquiry to 
providersupport@mahealth.net, or fax your inquiry to 617-988-8974. 

.



Vision Care

Material Order Form 

THE COMMONWEALTH OF MASSACHUSETTS

Executive Office of Health and Human Services 

Mail this form to:

MassCor/Massachusetts Correctional Industries
P.O. Box 466
Gardner, MA 01440

 
Homeless Person

Inquiry Telephone: 1-888-482-7331 Orders Fax: 1-888-698-2020 and 1-888-420-2047

Provider No.: 			Group Practice No.: 

Provider Name: 


Street: 


City: 	State: 	Zip: 


 Signature: 	Telephone No.: 
 


Member’s Name: 
 Last First MI

Gender: 	Date of birth: 

Member’s MassHealth ID No.: 			Coverage Type: TPL: Y N

Prior Authorization No.: 			Date sent: 

Frame Name: 	No.: 	Frame Color: 	No.: 	Alternate Color: 	No.: 

Eye Size: 	Bridge Size: 	Temple Length: 

 LENS TYPE – Please check Plastic
Poly-C 
Other (Non-contract material)

 single vision

 bifocal	rd seg	flat top 28

 lenticular aspheric	sv	rd seg

 COMPLETE IN MINUS CYLINDER

 			SPH	CYL	AXIS	PRISMS BASE DECENTER  IN OUT

 DISTR	R

 RXL		L

 
				Segment Height Inset Total Inset PD

 Add for near	R 				R	R	Far

			L				L	L	Near


Date Shipped: 	Date Received: 

Special Instructions:


Color

 pink 1
C1
 pink 2
C2
 Other
C3

(See regulations 130 CMR 
402.000 available at www.mass.gov/masshealth.)

Send original to MassCor. Keep a copy for your records.

VIS-1 (Rev. 04/09)