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.