Attachment C.xlsx
XLSX spreadsheet 11 KB Posted
- Solicitation number
- 36C24125R0088
About this file
This file is a detailed prescription eyeglasses order attachment for the Sioux Falls VA Health Care System. The document contains a specific patient order for eyewear with comprehensive prescription details, including sphere, cylinder, axis, and prism measurements for both right and left eyes. The order specifies progressive polycarb lenses with photochromatic tint, anti-reflective coating, and a brown EQ 230 frame (size 58-16), to be delivered to the veteran's home address.
The related federal contract opportunity is a Special Notice (Solicitation 36C24125R0088) for National Prescription Eyeglasses Manufacturing, issued by the Department of Veterans Affairs Veterans Health Administration Veterans Integrated Service Network 1. The attachment provides intricate medical specifications for a custom eyewear order, including detailed lens parameters, special instructions emphasizing medical necessity, and specific manufacturing requirements such as using the same base curve and measurements as a previous April 2022 order.
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Other files
| File | Type | Posted |
|---|---|---|
| SF1449 36C24125R0088 - Draft 2.0 - National Prescription Eyeglasses.pdf | ||
| SF30 36C24125R0088 0002.pdf | ||
| SAM Description - 36C24125R0088 0002_1.docx | DOCX document | |
| Attachment B Other Than Certified Cost or Pricing Data.xlsx | XLSX spreadsheet | |
| Attachment A Price Schedule National Prescription Eyeglasses.xlsx | XLSX spreadsheet | |
| Sol QA 36C24125R0088 RFP Draft 1 Nat Pre EG.pdf | ||
| 36C24125R0088 0001_1.docx | DOCX document | |
| 36C24125R0088 0001.pdf |
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Text version
Attachment C
| StationName | PatientIEN | PatientName | PurchaseOrderNumber | StreetAddress1 | StreetAddress2 | StreetAddress3 | City | State | Zip | RequestDateTime | ConsultReason | OrderContacts | IsRemake | LatestComment | VendorReferenceNumber |
| (438) SIOUX FALLS VA HCS | 123456 | Lastname,Firstname I | 1234567-1234 | 1234 Street Address | City | State | 12345 | Eyeglass |
Remake - DR RX CHANGE**
Firstname I Lastname 1234 Street Address City, State 12345
DISTANCE: Sphere Cylinder Axis Prism Base Prism Base No.1 No.1 No.2 No.2
RIGHT: -00.25 -00.50 165 02 OUT N/A N/A
LEFT : +00.75 -00.75 166 00 1/2 UP N/A N/A
PD Far: N/A PD Near: N/A
OD OS
Monocular: 34.0 34.5 Binocular:
NEAR ADDITION: RIGHT LEFT
Bifocal : +3.00 +Same as RIGHT Trifocal: +N/A N/A Height : 20/-- Same as RIGHT
Comments (MRX from physician note):
EYEWEAR OPTIONS: (NOTE **Indicates Medical Necessity is REQUIRED!)
Lens Type....: Progressive Lens Material: Polycarb Lens Tint....: Photochromatic [ ] Lenses Only [ ] Frames Only [ ] Use enclosed frames [ ] Supply Case [ ] Equal base curve OU [X] Anti-Reflective [ ] UV Coating
SPECIAL INSTRUCTIONS:
**Opposite signs is correct**
***USE SAME BC AND MEASUREMENTS AS APRIL 2022 ORDER***
MANUFACTURER:
Frame Name...: EQ 230 Color........: Brown Eyesize......: 58 Bridge Size..: 16 Temple Length:
DELIVERY INSTRUCTIONS:
[X] Mail to Veteran's home address (See bottom of page 1) [ ] Mail to Veteran's home address (See SPECIAL INSTRUCTIONS) [ ] Sioux Falls VAHCS Prosthetic Department [ ] Sioux Falls VAHCS Eye Clinic
VA Staff Responsible For Order:
Ordered By: EMPLOYEE NAME Email: employee.name@va.gov
Signed By: EMPLOYEE NAME Email: employee.name@va.gov N
File details come from the government source that posted it. Updated .