Form 999 2026

1. Click ‘Get Form’ to open form 999 in the editor.
2. Begin by entering your Last Name, First Name, and Middle Initial in the designated fields.
3. Fill in your Date of Birth using the MM/DD/YYYY format and provide your Social Security Number.
4. Complete your Mailing Address, including City, State, and ZIP Code.
5. Read the authorization statement carefully and sign as the Driver or Patient in the presence of a physician. Include the date of signature.
6. If applicable, indicate whether you are a regular eye care provider for this patient and specify how many times you have seen them in the past year.
7. In the Physician Section, fill out Distance Acuity details for both eyes with or without correction as required.
8. Provide any remarks regarding special restrictions or conditions if necessary.
9. Finally, complete your Office Mailing Address and include your License Number, Phone Number, and Signature along with the date.

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