Board Report is forwarded to the Navy Department for review and appropriate disposition, a report of the departmental action is entered on the current SF 600.
The purpose of DD form 771, Eyewear Prescription (fig. 10-12), is to order corrective prescription eyewear and to record information for ordering spectacles.
There are three major areas of consideration in completing a DD Form 771: patient information, prescription information, and miscellaneous information. These three critical areas are discussed as follows:
1. Patient InfomationThe specific information required is the patients name, rate, SSN, duty station, mailing ,addrcss, and military status. This information is required to establish eligibility and provide the requesting activitv with an address for the patient upon receipt of the completed spectacles.
2. Prescription InformationThe spectacle prescription is the technical portion of the order form and as such should be completed with great care, ensuring that the prescription is transferred in its entirety. The essential elements are interpupillary distance, frame size, temple length, plus and minus designators for both sphere and cylinder powers, segment powers and heights, prism, and prism base. It is not necessary to calculate decentration in the single vision or multifocal portions of the order. It is also unnecessary to try to transpose any prescription into plus or minus cylinder form. Leave the prescription as is, copy it onto the DD Form 771, and note in the remarks section that the prescription has been copied and is from the record.
3. Miscellaneous InformationThis area is reserved for any information you may feel will be helpful in either fabrication or determination of eligibility for your patient. Items that are normally entered in the space labeled special lenses or frames art types of multi focal lenses requested, any type of nonstandard lens or frame, verification of flight status for aviation spectacles, and justification for any request for unusual prescription items. Standard issue items can be determined from BUMEDINST 6810.4G.
All DD Forms 771 should be typewritten whenever possible. This practice eliminates any errors by misreading an individuals handwriting. Remember, if you are not underwvay, help is only as far away as your phone.
To ensure that the spectacle prescription that the physician has carefully determined to be necessary to satisfy the patients visual need is provided, it is critical that you, as the corpsman, take the time to correctly order the spectacles. Any omission of information or erroneous information will result in a delay at the fabricating facility or a patient receiving an incorrect pair of spectacle, or both. If individuals requiring spectacles are either without or wearing inappropriate spectacles, they are not going to be as effective as possible. This could have a detrimental effect on the readiness of that individuals command.
As a last effort to interpret a prescription that a physician has written, always make a photostatic copy of the prescription and send it to the fabricating facility, rather than try to copy over some information you are unsure of. Make sure that the copy of the prescription is accompanied by a completed DD Form 771.
Upon receipt of prescription eyewear from the ophthalmic laboratory, copy 2 of DD Form 771 shall be retained in the members medical treatment record.
Each members military health (dental) treatment record consists of the NAVMED 6150/ 10-19, Treatment Record Jacket, containing the following health care treatment forms, arranged in top-to-bottom sequence.
a. NAVPERS 5510/1, Record Identifier for Personnel Reliability Program (when appropriate)
b. SF 603A, Health Record-Dental Continuation (if applicable)
c. SF 603, Health Record-Dental
d. SF: 513, Consultation Sheet (when related to dental treatment)
e. SF 502, Narrative Summary
f. SF 509, Doctors Progress Notes
g. SF 515, Tissue Examination
h. SF 522, Request for Administration of Anesthesia and for Performance of Operation and Other Procedures