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CCPOA Member/Participant’s Name | |||||
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Social Security Number | |||||
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Address | |||||
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City |
State |
Zip | |||
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Telephone | |||||
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Name of Patient |
Date of Birth | ||||
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Your Doctor Must Complete and Sign the Following: |
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Name of Doctor/Optometrist | |||||
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Address | |||||
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City |
State |
Zip | |||
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Business Telephone Number | |||||
Date of Service: |
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VSP Exam Deductible |
Material Deductible | ||||
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Cost of Frame ( Less VSP Allowence): | |||||
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Second Pair | |||||
Date of Service: |
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VSP Exam Deductible: |
Material Deductible |
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Cost of Frame ( Less VSP Allowence): |
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Signature of Doctor/Optometrist: | |||||
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Date: | |||||