To process my medical claims for payment, I hereby authorize Susquehanna Eye Associates or their authorized agents, to release copies of my medical records and/or provide information regarding my exam and treatment rendered to your insurance carrier and/or any agent acting on the insurance carriers behalf. I hereby assign to Susquehanna Eye Associates all payments for medical services rendered to myself and/or my dependants, and I understand and agree that any services not covered by my insurance carrier are my financial responsibility.
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