CONTACT LENS SAVINGS STATEMENT

Doctor

Patient Name

Primary Authorization #

Secondary Authorization #

Date

OD CONTACT LENS

Boxes or Qty

Price Each

Total

$

$

OS CONTACT LENS

Boxes or Qty

Price Each

Total

$

$

Fitting Fees Section

Fitting Fees

$

Secondary Benefit Section

Secondary Benefit Amount

$

Sub-Total Section

Total Retail of Contacts

Insurance Benefit

Insurance Co-Pay

$

$

$

Total Cost for Contacts

$

COMMENTS