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Forms Available Online Washington State Health Care Authority 2016
Attach a copy of the prescription. Lenses for Date Ordered Date Delivered One Eye Both Eyes Glasses One Pair Two Pair Special Features Yes No Extra Charge if any Frames Single Vision Plastic Lenses Existing Bifocal Oversize New Trifocal Tinting of any kind Lenticular Blended focal Other Aphakic TOTAL CHARGES Including tax 0 Contacts Therapeutic Daily Wear Spherical Lenses Daily Wear Toric Hard Soft Gas Permeable Flexible Wear Supplier s Name Address and ZIP Code Tax ID Number TIN NPI...
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