I hereby authorize the Eye Institute of South Jersey, PC to furnish the insured’s insurance company all information which said insurance company may request concerning my present claim.

I hereby assign to the Eye Institute of South Jersey, PC all money to which I am entitled for expense relative to the services performed from time to time, but not to exceed my indebtedness to said doctors. It is understood that any money received from the above named insurance company over and above my indebtedness will be refunded to me when my bill is paid in full. I understand that I am financially
responsible to the Eye Institute of South Jersey, PC for charges incurred.

I request that payment of authorized Medicare and/or insurance benefits be made on my behalf to the Eye Institute of South Jersey, David R Pernelli, MD or Terrance K Heacox, Jr, OD for any services furnished to me by that physician/supplier/provider of care. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services (formerly HCFA), its agents or any insurance carrier I may have, any information needed to determine these benefits payable for related insurance carrier I may have, any information needed to determine these benefits payable for related services.