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Provider Utilization Report

Patient Name
Primary Member's Name (if different)
VPA Group/Member #
Date of Service

Services Provided: (Check applicable)

Eye Exam Lenses
S/V
B/F
T/F
Other 		Frames Contact Lenses Aphakic
OD
OS

If other, please explain:

Provider Name: Facility Number:
Address:
Telephone:
Fax:
Medical Referral (if applicable) to:

Dr.
Telephone:

Date:

Providers, we welcome your comments:


QualSight Preferred
LASIK Pricing