Attachment C _ 4-Sight Template.xlsx
XLSX spreadsheet 11 KB Posted
- Solicitation number
- 36C24126R0001
About this file
This file is a detailed prescription eyeglass order template for the Sioux Falls VA Health Care System (HCS). The template captures comprehensive patient and prescription details for a specific veteran, including prescription specifics for right and left eye (sphere, cylinder, axis, prism), lens options (progressive polycarb with photochromatic tint and anti-reflective coating), and frame specifications (EQ 230, brown, size 58/16). The order indicates a remake of previous eyeglasses with specific instructions to use the same base curve and measurements as a prior April 2022 order.
The template is directly related to the VA's solicitation #36C24126R0001 for "National Prescription Eyeglasses Manufacturing", which is set aside for service-disabled veteran-owned small businesses (SDVOSBs) under NAICS code 339115. The solicitation seeks a contractor to provide prescription eyeglasses for veterans across all VA sites of care, including CONUS and OCONUS locations. The procurement covers eyeglass manufacturing but explicitly excludes optician services, with the Product Service Code 6540 and a small business size standard of 1,000 employees.
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Text version
Attachment C – 4-Sight Template
| 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 .