Authorization:
I, with my signature, authorize Bloom Family Eye Surgeons LTD., and any employee working under the direction of the physician, to provide medical care for me, orto this patient forwhich I am legal guardian. I also authorize Bloom Family Eye Surgeons LID., to fuunish infonmation to the identified insurance carier(s) for prior authorization, pre-cestification, or payment of health care seryices. This information may include claims, copies of medical information, faxes and phone calls conceming care provided or proposed, I shall assign all payments for these services to this practice. Iunderstand that I am responsible for ell co-payments, amounts applied to deductibles and other amounts that may be deemed my responsibility by the insurance plan, as required by my contract with my insurance plan and state regulation.
