Eye Care for Kids Foundation
"Eliminating Blackboard Blindness"
Doctors Office:
Billing Personnel:
Date:
Claims
Approval Code:
Date of
Service:
(*Include RX if making a claim for High RX Poly)
Total Amount For Services Rendered:
Total Parent
Contribution:
Total In-Kind
Donation:
Subtotal:
Services Rendered:
Parent
Contribution:
Doctor In-Kind
Donation
Notes:
Subtotal, is the Total Amount Due Minus
The Parents Contribution.