Assignment and Release
I, the undersigned, certify that I (or my dependent) have insurance coverage (list below) and assign directly to Overlake Family Vision, PLLC 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 insurance. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize the use of this signature on all insurance submissions.