Optical order form template 2025

1. Click ‘Get Form’ to open the optical order form template in the editor.
2. Begin by entering your JAK Account Number and Provider Phone Number in the designated fields. Ensure that all information is printed legibly or typed for clarity.
3. Fill in the Provider Name and Provider Number/NPI, followed by the Dispensing Provider Address, City, State, and Zip Code.
4. In the Member Information section, input the Member ID Number and Prior Authorization if applicable. Complete the Member Name (Last, First, Initial) and their Address details.
5. Specify the Member's Gender and Date of Birth. Then proceed to fill out Frame/Prescription Information including Sphere, Cylinder, Axis, Dec, SV, FT 28, Prism details along with Lens Base for both Right (R) and Left (L) eyes.
6. Complete additional fields such as Add, Seg Hgt, Inset, Total PD Far and PD Near for both eyes.
7. Finally, provide Plan Frame details including Frame Name, Color, Eye measurements (Bridge and Temple). Include any Special Instructions if necessary.
8. Once completed, return this form via fax at 800-322-1822 or scan and email it to lab@jakopticallaboratories.com.

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