Savings Statement
Doctor
Authorization #
Patient
Date
LENS OPTIONS
Before InsuranceAfter Insurance
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
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 $