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Home » 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