The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the doctor. I understand that I am financially responsible for any remaining balance. I also authorize Premier Eyecare of Roswell or the insurance company to release any information required to process my claims. Furthermore, I hereby authorize Premier Eyecare of Roswell to disclose any necessary information to affiliated third party vendors as required to complete orders on my behalf; including but not limited to prescriptions, emails, and other contact information.