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For both examinations and eyewear can be claimed on this form. Only services listed on this form will be considered for reimbursement. 3. Make sure that all sections are completed, that you and the providers(s) have signed the form, and that all services, charges, and service dates have been entered. If the form is incomplete, additional information may be required. This may result in a delay of payment for eligible benefits. 4. Please submit claim reimbursement for each patient on a separate c.

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