Benefit Assignment Form

Phone: <a class="ecp-phone-call-phone" href="tel:705-503-3937" style="text-decoration:none"> 705-503-3937
Email: info@littlelakefamilyeyecare.com (Do not send personal health information by email.)

Name: Little Lake Family Eye Care
Address: 11 Lakeside Terrace #102, Barrie, ON, L4M 0H9, CA
Telephone: 705-503-3937
Price range: $000 - $300

I hereby assign benefits payable for the eligible claims to Little Lake Family Eye Care, who is responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to Little Lake Family Eye Care. In the event my claim( s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to Little Lake Family Eye Care for any services rendered and/ or supplies provided. I acknowledge and agree that the insurer/plan administrator is under no obligation t o accept this Assignment, that any benefit payment made in accordance with this Assignment will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the i nsurer/plan administrator will also be discharged of its obligation with respect to that benefit payment. I understand that this Assignment will apply to all eligible claims submitted electronically by Little Lake Family Eye Care and that I may revoke it at any time by providing written notice to the insurer/plan administrator. If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to Little Lake Family Eye Care.*
- I hereby consent to the above
Name*
First Last
Date*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Policy Holder's Name*
First Last
Policy Holder's Date of Birth*
Date Format: MM slash DD slash YYYY
Relationship to the Policy Holder*
- Self
- Spouse
- Child
Insurance Name*
Policy Number*
Member ID*
Signature*