SAVINGS STATEMENT
Doctor
Marcus A. East, M.D.
Ryan W. Lapour, M.D.
John G. Dodd, D.O.
Adam T. Shupe, O.D.
Patient Name
Primary Authorization #
Secondary Authorization #
Date
Before Insurance
After Insurance
Single Vision
[Lens Style]
$
$
Anti-Reflection Coating
Premium Anti-Reflection Coating
Factory Scratch Coating
Clarity Shield Scratch Coating
UV Protection
Ski Type Mirror
Mirror - Solid & Single Gradient
Glass
Trivex
Polycarbonate
Clear Glass
Hi Index 1.67
Hi Index 1.70
Transitions
Transitions Xtra Active
PGX
Semi-Rimless Edge
Drilled Rimless
Edge Polish
Polarized
Diamond Sunglass Tint
Solid Sunglass Tint
Diamond Solid Tint 1 & 2
Solid Tint 1 & 2
Gradient Diamond Tint
Gradient Tint
Aspheric
Prism
Oversize
$
$
Anti-Reflection Coating
Premium Anti-Reflection Coating
Factory Scratch Coating
Clarity Shield Scratch Coating
UV Protection
Ski Type Mirror
Mirror - Solid & Single Gradient
Glass
Trivex
Polycarbonate
Clear Glass
Hi Index 1.67
Hi Index 1.70
Transitions
Transitions Xtra Active
PGX
Semi-Rimless Edge
Drilled Rimless
Edge Polish
Polarized
Diamond Sunglass Tint
Solid Sunglass Tint
Diamond Solid Tint 1 & 2
Solid Tint 1 & 2
Gradient Diamond Tint
Gradient Tint
Aspheric
Prism
Oversize
$
$
Anti-Reflection Coating
Premium Anti-Reflection Coating
Factory Scratch Coating
Clarity Shield Scratch Coating
UV Protection
Ski Type Mirror
Mirror - Solid & Single Gradient
Glass
Trivex
Polycarbonate
Clear Glass
Hi Index 1.67
Hi Index 1.70
Transitions
Transitions Xtra Active
PGX
Semi-Rimless Edge
Drilled Rimless
Edge Polish
Polarized
Diamond Sunglass Tint
Solid Sunglass Tint
Diamond Solid Tint 1 & 2
Solid Tint 1 & 2
Gradient Diamond Tint
Gradient Tint
Aspheric
Prism
Oversize
$
$
Anti-Reflection Coating
Premium Anti-Reflection Coating
Factory Scratch Coating
Clarity Shield Scratch Coating
UV Protection
Ski Type Mirror
Mirror - Solid & Single Gradient
Glass
Trivex
Polycarbonate
Clear Glass
Hi Index 1.67
Hi Index 1.70
Transitions
Transitions Xtra Active
PGX
Semi-Rimless Edge
Drilled Rimless
Edge Polish
Polarized
Diamond Sunglass Tint
Solid Sunglass Tint
Diamond Solid Tint 1 & 2
Solid Tint 1 & 2
Gradient Diamond Tint
Gradient Tint
Aspheric
Prism
Oversize
$
$
Anti-Reflection Coating
Premium Anti-Reflection Coating
Factory Scratch Coating
Clarity Shield Scratch Coating
UV Protection
Ski Type Mirror
Mirror - Solid & Single Gradient
Glass
Trivex
Polycarbonate
Clear Glass
Hi Index 1.67
Hi Index 1.70
Transitions
Transitions Xtra Active
PGX
Semi-Rimless Edge
Drilled Rimless
Edge Polish
Polarized
Diamond Sunglass Tint
Solid Sunglass Tint
Diamond Solid Tint 1 & 2
Solid Tint 1 & 2
Gradient Diamond Tint
Gradient Tint
Aspheric
Prism
Oversize
$
$
Anti-Reflection Coating
Premium Anti-Reflection Coating
Factory Scratch Coating
Clarity Shield Scratch Coating
UV Protection
Ski Type Mirror
Mirror - Solid & Single Gradient
Glass
Trivex
Polycarbonate
Clear Glass
Hi Index 1.67
Hi Index 1.70
Transitions
Transitions Xtra Active
PGX
Semi-Rimless Edge
Drilled Rimless
Edge Polish
Polarized
Diamond Sunglass Tint
Solid Sunglass Tint
Diamond Solid Tint 1 & 2
Solid Tint 1 & 2
Gradient Diamond Tint
Gradient Tint
Aspheric
Prism
Oversize
$
$
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
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