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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
Doctors Robert, Stephen, Christopher, Andrew Brown and staff of Brown Eye Care want to take this opportunity to express our appreciation for the patience given to us during this pandemic. It has been a process for the entire staff and doctors. It is our goal to serve our patients safely as we get through this crisis together and to continue to flatten the curve.