Monthly Attestation | SpectOcular

Currently by email. During the pilot, Dr. Chavala emails you the attestation at the start of each month and you can simply reply to it. Use this form only if you were asked to, or if you prefer to attest online — either way is valid.

Attestation

Site

Month being attestedThe month that has ended (e.g. on November 1, attest for October).

Eyecare professional name

E-mail

Practice / entity (payee on your W-9)

For the month above, I attest that:

I remained available to perform the Eyecare Professional services described in Article III-A of my Eyecare Professional Agreement with SpectOcular LLC. I performed any of those services that SpectOcular requested, or that were reasonably necessary, during that month. I understand the $400 monthly retainer is a fixed fee set in advance and is not conditioned on, and does not reflect, any referrals, scans, study enrollments or other business between me or my practice and SpectOcular. This information is true and complete to the best of my knowledge.

Services this month (optional, helpful for the record)

Notes

Signature

Typed electronic signature (full legal name)

Date

I agree that typing my name above is my electronic signature on this attestation.

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