ASSIGNMENT OF INSURANCE  BENEFITS

SIGNATURE ON FILE

PATIENTS NAME (Please Print)

First                                                              Middle                   Last                                                        

Mailing Adress                                             Apt. #             City                                  St.         Zip           

 Sex:  M     F      Date of Birth ____/____/____   Age____   SS#_____________________ Marital Status_____

INFORMATION OF POLICY HOLDER OR PERSON RESPONSIBLE:    

 (Circle One)  Self    Spouse    Parent or Legal Guardian

Full Name______________________________________ SS#______________________

Employer___________________________________________________ Date of Birth_____/_____/_____

                                                                                                                                               mo    day      yr

Insurance Company___________________________________________Group#________________________________

Name of Relative Not Living With You

__________________________________________________________________________________________________

    Name                                                   address                                                                                           phone

Do You Have A Secondary Insurance?__________________________________________________________

I  authorize  the  release  of  information  relating  to  all  claims  for  benefits  submitted  on  behalf  of  myself  or  my  dependents.

     My signature on this document authorizes Precision Optical, P.C.  to  submit  Insurance  and/or  Medicare  claims     for  benefits  on  services  rendered,  to  be  rendered,  and/or  on  materials  furnished.   I  certify  the  information  given  by  me  is  true  and  correct.   I   hereby assign payment directly to Precision Optical, P.C.  for these benefits.

_______________________________________             ______________________

        Signature                                                                                          date

     I  understand  that  I  am  financially  responsible  for  all  charges  incurred,  including  unpaid  insurance  claims. Co-pays, deductibles, and non-covered amounts are due when services are rendered.  There will be a finance charge up to 1.5% /mo. applied to any balance that is unpaid. Verification of benefits does not guarantee payment.

_______________________________________             ______________________

        Signature                                                                                          date