The above information is true to my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize La Bleu Optique or insurance company to release any information required to process my claim. Payment is expected at the time of visit unless we participate with your insurance plan. Any Copayment required under your plan is due at time of visit. I have received the Notice of Privacy Practices and I have had an opportunity to review it, and take a copy for my records.