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OPTICAL REIMBURSEMENT REQUEST PATIENT NAME THIS SECTION TO BE COMPLETED BY PATIENT MEDICAL RECORD NUMBER (HORN) HOME ADDRESS BIRTHDATE (month/date/year) CITY STATE REGION WHERE SERVICES PROVIDED GEORGIA

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What is this section to be?

This section is to be completed for tax purposes.

Who is required to file this section to be?

All individuals earning income are required to file this section.

How to fill out this section to be?

This section can be filled out online or by mailing in a paper form.

What is the purpose of this section to be?

The purpose of this section is to report income and calculate taxes owed.

What information must be reported on this section to be?

Information such as income, deductions, and credits must be reported on this section.

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