Receipt Requests

(for tax deductibility/write-off, FSA/HSA reimbursement, personal records, etc.)

*Please note that requests require seven (7) business days of processing time.

"*" indicates required fields

Patient Name*

Date of Birth*

Phone*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Notes

Brinton Vision is a private-pay refractive surgery practice and does not participate in the Medicare program or submit claims to Medicare. All services provided at Brinton Vision are paid for directly by the patient. At my request, Brinton Vision is providing an itemized receipt that includes procedure descriptions or billing codes for my personal records or for submission to a private health insurance plan. I understand and agree to the following: • Brinton Vision did not submit any claim to Medicare for the services I received. • The receipt is being issued solely at my request after payment for services. • Brinton Vision makes no representation that any service will be reimbursed by any insurance plan. • I am responsible for determining whether my insurance plan may reimburse any portion of these services.*

I agree

Signature*

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Receipt Requests

(for tax deductibility/write-off, FSA/HSA reimbursement, personal records, etc.)

Have you had LASIK or lens implant surgery in the past?