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Primary Care Physician
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I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled including Medicare, private insurance and any other health plans to Brown Eye Care Associates. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all services rendered that are considered out of network or any balance that is not covered by my insurance carrier. I authorize the use of this signature on all insurance submissions. I authorize Brown Eye Care Associates to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit.
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Signature of Responsible Party