Risk Management
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Contact Lens Prescriptions- Patient Forms
To assist your practice with patient requests for contact lens prescriptions, the following sample-patient forms are offered below. We include a template for a Contact Lens Agreement that would reflect your practice’s policy regarding contact lens prescriptions. See the FTC Contact Lens Rule, effective 10/16/2020, for compliance requirements for contact lens prescribers: FTC CL Rule
If you have questions, please contact OMIC’s Risk Management group. Email us at riskmanagement@omic.com or call us at 1-800-652-6642, enter 4 for Risk Management.
Contact Lens Request – Denied Follow Up Care Needed
Contact-Lens-Prescription COPY Requested
Sample CL Prescription Received-Patient Signature
Sample CL Agreement- New FTC CL Rule effective 10-16-2020
Medical Record Request Includes Expired Contact Lens Prescription
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