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Home » INSURANCE INFORMATION Custom Vision, Inc.

INSURANCE INFORMATION Custom Vision, Inc.

  • Date Format: MM slash DD slash YYYY
  • I, the undersigned have insurance coverage as mentioned below and assign directly to Custom Vision, Inc., DBA Custom Eyes all medical and vision benefits, if any, otherwise payable to me, for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all of my insurance submissions.
  • MEDICAL INSURANCE

  • Date Format: MM slash DD slash YYYY
  • VISION INSURANCE

  • Date Format: MM slash DD slash YYYY
  • I ACKNOWLEDGE THAT I ACCEPT RESPONSIBILITY FOR ALL INSURANCES CHARGES NOT PAID

  • If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.
  • I have read and understand this form. I am signing it voluntarily.
  • Date Format: MM slash DD slash YYYY

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