Explanation of Benefits Documents
Please find below several examples of Explanation of Benefits (EOB) documents.
Purchase Charge Documents/Patient's Invoice for OZURDEX® (dexamethasone intravitreal implant) Treatment
Patient's Invoice for OZURDEX® Treatment is the receipt given to patients as proof of payment. The format of this document will vary by office.
Physician Attestation Form
This may be uploaded in place of Patient's Invoice for OZURDEX® Treatment (patient invoice indicating their co-pay paid) if the Patient's Invoice for OZURDEX® Treatment is not available. Note: If you have checked the co-pay attestation box on the reimbursement form, it is not necessary to submit the Patient's Invoice or the signed Physician Attestation Form.
Download the form