Authorization: I, with my signature, authorize Bloom Family Eye Surgeons LTD., and any employees working under the direction of the physician, to provide medical care for me, or to this patient for which I am legal guardian. I also authorize Bloom Family Eye Surgeons LTD., to furnish information to the identified insurance carrier(s) for prior authorization, pre-certification, or payment of health care services. This information may include claims, copies of medical information, faxes and phone calls concerning care provided or proposed. I shall assign all payments for these services to this practice. I understand that I am responsible for all 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.
