Vision Insurance Claim
Claimant Information
Name: [Your Name]
Policy Number: 123456789
Address: 123 Elm Street, Cityville, ST 12345
Phone Number: (123) 456-7890
Email: [Your Email]
Provider Information
Name: Dr. John Smith
Practice Name: Cityville Vision Care
Address: 456 Oak Avenue, Cityville, ST 12345
Phone Number: (098) 765-4321
Vision Care Services and Expenses
Date of Service | Service Description | Provider | Cost |
|---|
01/15/2050 | Comprehensive Eye Exam | Dr. John Smith | $150.00 |
01/18/2050 | Prescription Glasses | Cityville Optics | $300.00 |
02/01/2050 | Contact Lenses (3 months supply) | Cityville Optics | $120.00 |
Total Cost: $570.00
Supporting Documentation
The following documents are attached to support this claim:
Itemized bill for the comprehensive eye exam.
Invoice for prescription glasses.
Receipt for contact lenses.
Copy of the prescription from the eye care professional.
Claimant's Declaration
I, [Your Name], hereby declare that the information provided in this claim is true and correct to the best of my knowledge. I understand that any false statement made in this claim could lead to a denial of reimbursement and may be subject to legal action. I authorize my insurance company to contact my eye care provider for any further information necessary to process this claim.
[YOUR NAME]
[DATE SIGNED]
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