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Home ยป INSURANCE VERIFICATION, AUTHORIZATION AND ASSIGNMENT OF BENEFITS

INSURANCE VERIFICATION, AUTHORIZATION AND ASSIGNMENT OF BENEFITS

  • I authorize the use of my personal information provided to verify, authorize, and file claims for insurance benefits related to professional services rendered.
    I authorize the direct payment of insurance benefits to Maison Optique Vision Center for professional services rendered.
    I understand that I am financially responsible for balances that my insurance company has determined to be the responsibility of the patient.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

We are still here for you!
Despite being temporarily closed for routine eyecare, we continue to provide helpful services for our patients, such as emergency eyeglass repairs/warranties and contact lens orders.
Please CLICK HERE for more information.
Be well!