I certify that I, and/or my dependent(s) have insurance coverage with the companies listed above. I assign directly to Wallingford Eye Care Center and my assigned provider within the practice 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 authorize the use of my signature on all insurance submissions.
My assigned provider at Wallingford Eye Care Center may use my health care information and may disclose such information to the above named insurance companies and their agents for the purpose of obtaining payment for services and determining insurance benefits for the benefit payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.