INSURANCE AGREEMENT AND RELEASE
I, the undersigned, certify that I or my department have insurance coverage with the above Insurance Company and assign directly to Moon Valley Eyecare all insurance 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 my insurance, final amount based upon EOB. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.