If you don’t know an answer to any question then put N/A

Mr./Ms./Mrs./Miss/Dr.

PERSON RESPONSIBLE FOR THIS ACCOUNT

AUTHORIZATION/RESPONSIBILITY AGREEMENT

Payment is expected at the time professional services are rendered. A 50% deposit is required before materials are ordered; balance is due upon delivery of materials.

I have requested Marston Optometry to bill my insurance company for covered services on my behalf. I clearly understand that it is still my responsibility to make sure that the bill is paid in a reasonable time. If for any reason any portion of my bill is not paid by my insurance, I further agree to make arrangements for prompt payment of the bill.

I hereby authorize any insurance company to pay the proceeds of any of my benefits due me directly to Marston Optometry a copy of this can be considered as an original for insurance purposes.

In order to process a claim for benefits, I authorize Marston Optometry or my insurance company to release all information with respect to myself or any of my dependents which may have a bearing on the benefits payable under any plan providing benefits or services. I certify that the information provided by me in support of claims is true and correct. A photocopy of this authorization shall be considered as effective and valid as the original.