Doctor
Authorization #
Patient
Date
LENS OPTIONS
Before InsuranceAfter Insurance
Lens Style: Trifocal
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
FRAME OPTIONS
Retail Value
$
Insurance Benefit
$
Frame After Insurance
$
SECONDARY BENEFIT
$
CO-PAY and TOTALS
Total Retail of Glasses
$
Total Insurance Benefit
$
Insurance Co-Pay
$
Patient Pays
$