Insurance Agreement and Release
I, the undersigned, certify that I or my dependent have insurance coverage with the above Insurance Company and assign directly to Somerton Eyecare Center, Inc 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. 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. Please check the method of today's payment below.