Vision Care
Material Order Form
T H E C O M M O N W E A LT H O F M A S S A C H U S E T T S
Executive Office of Health and Human Services
VIS-1 (Rev. 01/12)
Homeless Person
Mail this form to:
MassCor/Massachusetts Correctional Industries
P.O. Box 466
Gardner, MA 01440
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: Date of Birth:
Last First MI
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 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
DIST R
RX
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 at 130 CMR
402.000, accessible at
www.mass.gov/masshealth.)
Send original to MassCor. Keep a copy for your records.
Diagnosis Code
367.0 – Hypermetropia
367.1 – Myopia
367.20 – Astigmatism
367.4 – Presbyopia
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 falsification, omission, or concealment of any material fact contained herein.
Signature:
Date:
