Vision Insurance Claim
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]
