Itemized Statement Of Services Form
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1U L T R A - V I S I O N
___________________________________________________________________________________________________________
MEMBER____________________________________________________________________________ SOCIAL SECURITY NO._________________________
___________________________________
___________________________________
__________________________
ADDRESS
Street
City
State & ZIP Code
SCHOOL DISTRICT OR GROUP_____________________________ DOES YOUR SPOUSE HAVE A SEPARATE POLICY WITH SET? _____YES
_____NO
_________________________________________________________________________________________________________________________________
NAME OF PATIENT:________________________________________ BIRTHDATE:_______________ RELATIONSHIP:________________________________
_________________________________________________________________________________________________________________________________
I T E M I Z E D S TAT E M E N T O F S E R V I C E S
_________________________________________________________________________________________________________________________________
DATE OF SERVICE(S):_________________________
EXAMINATION:
LENSES:
CONTACTS:
EXAM
$
SINGLE VISION
$
HARD LENSES
$
REFRACTION
$
BIFOCAL
$
SOFT LENSES
$
VISION ANALYSIS
$
TRIFOCAL
$
DISPOSABLE
$
OTHER
$
PROGRESSIVE
$
SOLUTIONS
$
OTHER
$
PHOTOGRAY
$
KIT/HEATER
$
TINT
$
OTHER
$
FRAMES:
$
OVERSIZE
$
OTHER
$
GRAND TOTAL
$
OTHER
$
OTHER
$
_________________________________________________________________________________________________________________________________
P R O V I D E R I N F O R M AT I O N :
NAME____________________________________________________TIN#__________________________TELEPHONE NO.___________________________
___________________________________
___________________________________
__________________________
ADDRESS
Street
City
State & ZIP Code
_________________________________________________________________________________________________________________________________
TO BE COMPLETED BY THE EMPLOYEE:
I authorize payment of vision benefits to the physician or supplier described above.
SIGNATURE____________________________________________________ DATE ____________________
_________________________________________________________________________________________________________________________________
This is an itemized Statement only and is not intended to identify covered charges.
MAIL TO:
TOLL-FREE: 1-800-292-5421
SET-SEG
LOCAL:
1-517-482-0871
415 W. KALAMAZOO ST.
LANSING, MI 48933
FORM NO. 410 (10-99)
ATTN: VISION CLAIMS
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