Skip to site content

Indian Health Service The Federal Health Program for American Indians and Alaska Natives


     Indian Health Manual
Print This Page >

Part 3, Chapter 9:  Manual Exhibit 3-9-E

Optical Prescription Patient Paid Order


  1. Vendor:______________________________________________________

  2. IHS Ordering Facility:___________________________________________

    Chart #:_________________________

    Patient Name:___________________________________

    Address:_____________________________________________________

    Phone:______________________

  3. Vendor, please supply the following Rx materials and services only after verifying and accepting the attached payment as payment in full.  If the attached is inadequate, do not fill or start work on this order.  Instead return the form and payment with the correct costs indicated.

  4. Rx/Order: [____________________________]

  5. See attached invoice - or $_______________________

  6. Receipt #______________________ Total Cost $_______________________

  7. Dispensing instructions:______________________________________


  8. ___________________________________________________________________

  9. _______________________________________________
    Authorized Signature
    ____________________________
    Date


  10. Date mailed to vendor (Certified mail):_____________________

  11. By:________________________________________________________________

  12. Date received from vendor:___________________________

  13. By:________________________________________________________________

  14. Results & Action taken:___________________________________________

  15. __________________________________________________________________

  16. Date Verified:___________________________

  17. By:________________________________________________________________

    Reaction:_________________________________________________________

  18. Date & how patient notified:___________________________

  19. By:________________________________________________________________

  20. Date dispended:___________________________

  21. By:________________________________________________________________

    Reaction:_________________________________________________________

  22. Instructions given:_______________________________________________

  23. __________________________________________________________________

    __________________________________________________________________

  24. _______________________________________________________________

  25. Patient or representative's signature Date

    (This signature acknowledges receipt pf ordered items and understanding of instructions.)

    (Staple money order here - see next page for instructions.)


----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------

To pay for prescription optical lab services the:

----------------------------------------------------------------------------------------------------------------

Eye Clinic has received and forwarded to a qualified vendor a money order in the amount of $________________

From: _____________________________________________________________

Received by:_____________________________________________________________

Date: _____________________________________________________________

Receipt #:_____________________________________________________________

----------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------------

IHS Optical Prescription Patient-Paid Order Form Instructions:
  1. Complete the top of this form and items 1 through 6 as appropriate.

  2. Retain a photocopy of this form with the patient's payment stapled to the bottom where indicated.  Accept only money order or cashier's check for the exact amount made payable to the vendor.  Place the photocopy in a three ring binder "orders out" section.  Use only certified mail to send the original form with the attached money order to the vendor.

  3. Upon receiving the completed order from the vendor, complete items 7 through 13.  If order was filled correctly, notify the patient to come in for dispensing.  Invoice copies, etc. should be stapled to the back of the completed form and copies may be used to initiate payment to the vendor.

  4. At dispensing, complete item 14 and file the form alphabetically.

  5. Incorrect work should be returned with instructions on the original form and on the photocopy which goes to an overdue binder section.




Back To Top  |  Previous Page
CPU: 31ms Clock: 0s