MassHealth
THE COMMONWEALTH OF MASSACHUSETTS Executive Office of Health and Human Services

Vision Care
Material Order Form

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:
Telephone No.:

Member’s Name:
Last
First
MI
Date of Birth:
Member’s MassHealth ID No.:
Gender:    M   F

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
  single vision
  bifocal 
  lenticular aspheric
  Other (Non-contract material)
  rd seg
  sv
  fat top 28 (       )
  rd seg

COMPLETE IN MINUS CYLINDER

		SPH		CYL	AXIS	PRISMS		BASE	DECENTER	
DIST	R	 							IN   OUT								
RX	L									
			Segment Height  Inset    Total Inset    PD							
Add for near	R			R		R	Far	
		L			L		L	Near	
Color		
pink 1	C1 
pink 2	C2 
Other 	C3 
(See regulations at 130 CMR 402.000, accessible at www.mass.gov/masshealth.)		
		
Diagnosis Code		
367.0 - Hypermetropia	
367.1 – Myopia	
367.20 – Astigmatism	
367.4 – Presbyopia	

Date Shipped:
Date Received:
Special Instructions:

I certify that the information on this form, and any attached statement that I have provided,
has been reviewed and signed by me, and is true, accurate, and complete, to the best of my
knowledge. I understand that I may be subject to civil penalties or criminal prosecution for
any falsifcation, omission, or concealment of any material fact contained herein.

Signature:
Date:

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

VIS-1 (Rev. 01/12)