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
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. 04/09)
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:
Signature: Telephone No.:
Member’s Name: Gender: Date of birth:
Last First MI
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
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 130 CMR
402.000 available at
www.mass.gov/masshealth.)
Send original to MassCor. Keep a copy for your records.
Print
Reset Form