SAVINGS STATEMENT

Doctor

Patient Name

Primary Authorization #

Secondary Authorization #

Date

Before Insurance

After Insurance

Progressive [Lens Style]

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Frame Section

Frame Retail Value

Insurance Benefit

Frame Cost After Insurance

$

$

$

Secondary Benefit Section

Secondary Benefit Amount

$

Sub-Total Section

Total Retail of Glasses

Total Insurance Benefit

Insurance Co-Pay

$

$

$

Total Cost for Glasses

$

COMMENTS