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Patient Name: Provider Name: Date of Service: Service - MES Vision

Patient Name: Provider Name: Date of Service: Service - MES Vision 2026

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The document is a patient survey from Medical Eye Services (MESVision) aimed at gathering feedback on the vision plan services provided. It includes questions regarding the patient's experience with their examining and eyewear providers, quality of service, customer support interactions, and overall satisfaction. The survey also seeks to understand language preferences and the availability of educational materials related to vision care.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the 'Patient Name' in the designated field. Ensure that you input the full name as it appears on official documents for accuracy.
Next, fill in the 'Provider Name' section. This should reflect the name of the healthcare provider who conducted your vision examination.
In the 'Date of Service' field, enter the date when you received your vision care services. Use the format MM/DD/YYYY for consistency.
For 'Service Type', specify the nature of the service provided, such as an eye exam or eyewear fitting. This helps in categorizing your experience accurately.
Proceed to rate your experiences with various aspects of your visit, including provider quality and customer service, using the provided rating scale.

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What goes in box 23 on a CMS 1500?

If the provider did not perform a global service and instead performed only one component, the date of service for the technical component would be the date the patient received the service, and the professional component would be the date the review and interpretation is completed.

What is considered the date of service?

The date of service is the date of responsibility for the patient by the billing physician. This would also include when a patients dies during the calendar month.

What is the date of service for a patient?

The date of service is the date of responsibility for the patient by the billing physician. This would also include when a patients dies during the calendar month. When submitting a date of service span for the monthly capitation procedure codes, the day/units should be coded as 1.

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