Detailed Written OrderTHIS IS NOT A STAND-ALONE DOCUMENT IT MUST BE ACCOMPANIED BY MEDICAL RECORDS TO SUBSTANTIATE MEDICAL NECESSITY (i.e.: OPERATIVE REPORT, CLINICAL NOTES AND/OR PHYSICIANS RECOMMENDATIONS). YOU MAY ATTACH A CLINIC NOTE OR LETTER, OR YOU MAY FAX THE DOCUMENTATION TO (888) 977-5399.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Ordering Provider Name *FirstLastNPI *Referring Clinic/Physician Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeContact email *Insurance companies typically require a copy of this order. An order should appear in the records of both the referring provider and the ocularist and be available upon request by the payor. By providing your email, you will be sent a copy of this order.I am referring... *FirstLast(DOB) *Phone number to contact the patient: *for... *V2623 - PROSTHETIC EYE, PLASTIC, CUSTOM (New or replacement)V2624 - POLISHING/RESURFACING OF OCULAR PROSTHESIS (typically done every 6-12 months)V2625 - ENLARGEMENT OF OCULAR PROSTHESIS (used for children as they are growing)V2626 - REDUCTION OF OCULAR PROSTHESISV2627 - SCLERAL COVER SHELL (New or Replacement, a very thin prosthesis used for atrophic globe)V2628 - FABRICATION AND FITTING OF OCULAR CONFORMER (used for microphthalmos or anophthalmos)V2629 - PROSTHETIC EYE, OTHER TYPE (Other - please specify)Cleaning/Polishing DiagnosesZ97.0 - Presence of artificial eyeNew Prosthesis Diagnoses (check any that apply)Z44.21 - Encounter for fitting and adjustment of artificial RIGHT eyeZ44.22 - Encounter for fitting and adjustment of artificial LEFT eyeZ90.01 - Acquired absence of eyeQ11.1 - AnophthalmosQ11.2 - MicrophthalmosH44.521 - Atrophy of the globe, right eyeH44.522 - Atrophy of the globe, left eyeH44.523 - Atrophy of globe, bilateralOtherOther DiagnosisI recommend cleaning/polishing...every 6 months.each year.Other... (please describe)of the... *left eyeright eyebilaterialThis patient has a history of (1-3 sentences describing the eye loss and why the patient needs a new prosthesis)... *Please upload a clinic note (must at least mention the absence of the eye) * Click or drag files to this area to upload. You can upload up to 3 files. Signature of Ordering Provider *Clear SignatureSubmit