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Rules and Regulations:
Piccolo is a Registered Trademark of Shamir Insight Inc. ReCreating Perfect Vision is a Registered Trademark of Shamir Insight Inc. Eye-Point Technology is a Registered Trademark of Shamir Insight Inc. Federal Law and laws of some states prohibit payment or receipt of any form of compensation where the product is paid for, in whole or in part by a federal or state funded health care programs (such as Medicare or Medicaid), and such transactions are not eligible for payment under the SuperLite program. You are solely responsible for submission of eligible claims only. If, for any reason, such as clerical error, you receive payment under the SuperLite program based on a ineligible transaction, you must, upon request of the Secretary of the United States Department of Health Services or counterpart state agency, report the full amount of SuperLite program received based on that transaction.
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For more information about our products visit:
www.shamirlens.com
or contact us at
information@shamirlens.com