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.Patient Name* First Last Patient Date of Birth* MM slash DD slash YYYY Date* MM slash DD slash YYYY Patient Signature*
