Prescription Eyewear - Order Form
3M
2925 Gary Dr. Plymouth, IN 46563
Fax: 800.945.2828
Tel: 800.982.2828
/
Order Date
(mm/dd/yy)
EA
Order Form#
.
/
Company:
05913056
.
PO#
INDEX#
(REQ#)
(Required)
EMP LAST NAME
(Required)
.
.
Bill-To:
01004956
OREGON STATE UNIVERSITY
ATTN ACCOUNTING OFFICE
108 OAK CREEK BLDG
CORVALLIS
OR 97331
.
EMP FIRST NAME
(Required)
.
OSUID#
(EMP#)
(Required)
Ship-To: ____________ (Account#)
.
EMP DEPT
EMPLOYEE PHONE
(Required)
OREGON STATE UNIVERSITY
ENVIRONMENTAL HEALTH & SAFETY
100 OAK CREEK BLDG
CORVALLIS
OR 97331
.
. 16 digit SCCID (xxxx-xxxx-xxxx-xxxx)
.
.
Exp
. (mm/yy)
Amount
* Signature required for Emp Credit Card charges
Lens Material
Lens Style
Frame Only
Patient’s Own Frame
Lenses Only
Progressives
Single Vision
Base PAL Clear CR39/Poly
SolaOne
BiFocal
28
35
35
SolaMax
TriFocal
Outlook
28
Occupational 14 mm sep
AO Compact
VIP
35
28
AO Easy
Other ___________
Duty to warn: Polycarbonate is the most impact resistant material available & is highly recommended
Other
Glass
Polycarbonate
Plastic CR-39
Tints & Coatings
Clear
Tint ________
Photochromic
Transitions
Sphere
Prescription
Lens Style
C
C
C
C
C
C
C
C
C
C
E
E
No charge for Scratch Resistant Coating
Polarized
SuperCote
AR W/SuperCote
AR W/SuperCote PLUS
Transitions XTRActive
Single Vision
BiFocal
TriFocal
Computer Lens
Base PAL (min fitting ht 18mm)
I Hoya Amplitude
Outlook, SolaMax
II AO Compact, VIP, Image,
Adaptar
III Easy, Illumina, EOS
Natural
III-Plus Comfort
IV SolaOne, Compact Ultra
C
C
C
E
C
C
V
Zeiss GT2
Cylinder
Prism
Base
Left OS
Near PD
Left OS
Side Shields
proford Nov 2012
05913056 00001 04/04/13
44.00
82.50
E
137.50
C
.00
C
C
C
E
.00
.00
.00
44.00
.00
.00
.00
27.50
77.00
.00
Tint 1 Plastic/Poly
Tint 2 Plastic/Poly
Tint 3 Plastic/Poly
UV
C
C
C
C
.00
.00
.00
.00
A/R Coating
SuperCote
AR W/SuperCote
AR W/SuperCote PLUS
Anti-Fog Coating
C
C
C
E
C
.00
.00
.00
27.50
.00
Who R CoPay
Amt
Pays E
Q
Specialty Lenses
Occupational
Full Line MultiFocals
C
E
C
.00
171.60
.00
Polish Edges
C
.00
SideShields
Who R CoPay
Pays E
Amt
Q
C Y
.00
Who R CoPay
Amt
Pays E
Q
C
If Dispensing Fee is employee paid, collect at time of order
* Credit Card Authorization
Eye
Bridge
Color
Temple
Signature
Supervisor
. / Contact
Phone __________________
Permanent
* Select Styles Only
*Integrated
Special Instructions
.
.
E
E
Employee co-payments by SECURE CC ID are due at time
of order and may be faxed to: 800.945.2828.
Right OD
Style Name, Model
33.00
Who R CoPay
Amt
Pays E
Q
Tints & Coatings
Dispensing Fee
Dist PD
.00
E
C
C
Transitions, LifeRx
C
Transitions XTRActive
E
Intimidator (Polarized Mirror) E
Polarized / Coppertone
C
DriveWear
NA
Dispensing
Seg Hgt
C
Who R CoPay
Amt
Pays E
Q
Permanent
Detachable
FOR FUTURE USE
Right OD
Add Power
.00
.00
.00
171.60
.00
.00
Specialty lenses include Slab-Offs, Myodiscs, cataracts plus
special Glass treatments such as Noviol and Didymium
Other ______________
Axis
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
33.00
55.00
Who R CoPay
Amt
Pays E
Q
Glass
Plastic CR-39
High-Mid Index
Trivex
Other Options
Anti-Reflective
UV
Anti-Fog
CoPay
Amt
Who R
CoPay
Pays E
Amt
Q
Do NOT enter
Lens Options
a real credit
Photochromic Glass
card number
Colored Glass
.
Company
Frame
Base Group
Group A
Group B
Group C
Group D
Group D PLUS
Group E
Group F
Group G
Group G PLUS
Group H
Wrap Srx
Polycarbonate
Obtain Secure Credit Card ID from: https://aosafetysrx.com/secure_id OR 866.235.5506
*Employee
Who R
Pays E
Q
Frame Groups
Lens Material
.
VI,MC,AX,DI
Who pays: (C)ompany, (E)mployee, NA=not allowed, REQ=Required
X Detachable
*Perforated
T-LOC
Gray
*Breeze Catcher
*Steel
EMPLOYEE PAYS THEIR LISTED FEES AT TIME OF ORDER
BY CHECK OR CREDIT CARD
Fax
__________________
Signature
Doctor / Optician
Phone __________________
Fax __________________
Signature
* SRx eyewear available exclusively from 3M. BreezeCatcher®, DX®Rx Anti-Fog, SuperCote™ are trademarks of 3M. AO Compact™, AO Easy®, SOLA ONE® and Solamax™ are registered trademarks of Zeiss Vision.
Transitions® is a registered trademark of Transitions Optical. Varilux Comfort® is a registered trademark of Essilor International. Outlook® is a registered trademark of Vision-Ease. CR-39® is a registered trademark of PPG
Industries. T-LOC and Titmus are registered trademarks of Honeywell.
Prescription Safety Eyewear Program Instructions
Employee Instructions:
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prescription eyewear may be ordered without this form.
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Eye Care Professional Instructions:
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3M Occupational Health and
Environmental Safety Division
Updated: 7/22/11
3M Company
Occupational Prescription Eyewear
5457 West 79th Street
Indianapolis, IN 46268
Personal Credit Card User Information
To adhere to the Federal Banking regulations 3M does not accept order forms containing actual credit card
information. Please follow the directions below for proper processing of your order.
Note: Please disregard these instructions if your payment is made with a personal check or money order.
There are two options you may use to obtain your Secure CC ID Number:
Option 1 - Web Based
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§
§
§
§
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§
Access web site at www.aosafetysrx.com/secure_id
Enter Credit Card number
Enter Credit Card expiration date
Enter Card Holder’s name as it appears on the card
Enter Card Holder’s email address; receipt will be sent via email to card holder for expense reporting *
Enter Card Holder’s contact telephone number
Enter Card Holder’s billing address, including city, state and zip code
Select AUTHORIZE to obtain your Secure CC ID number;
—You can write this number down in the Secure Credit Card ID section on your 3M order form or if you
provided an e-mail address, an e-mail will be sent to you with your CC ID number which can be printed.
You will need to bring this number with you when you order your eyewear.
Please note: If you have a need to use multiple credit cards for your purchase/s, you will need a separate Secure CC
ID Number for each card. Select Submit Another to obtain a second Secure CC ID Number for a different credit
card.
* If a receipt is required for your purchase the web based option must be used
Option 2 - Telephone Access
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§
§
§
§
§
Dial toll-free number 866.235.5506
Select Option 2 for a Secure Credit Card ID Number.
Enter Credit Card number followed by the # sign
Enter Credit Card expiration date; format should be MMYYYY
Enter Card Holder’s billing zip code
You will be provided with a Secure CC ID Number; write this number down and bring it with you to the
Eye Care Professional (optician)—You can write the Secure CC ID Number on the order form in the
Secure Credit Card ID section
* The Option 2 will not provide you with a receipt for your purchase. Please refer to Option 1.
IMPORTANT NOTE: The Secure CC ID Number process does not charge anything to your Credit Card.
Appropriate charges will be applied to your credit card after you have selected your eyewear with the Eye
Care Professional (optician) and only if your eyewear selection includes co-pay items.
3M Occupational Health and
Environmental Safety Division
Updated: 01/30/2012
3M Company
Occupational Prescription Eyewear
5457 West 79th Street
Indianapolis, IN 46268
3M.