I hereby authorize Laster Eye Center to give my insurance company or companies, my attorney, or my physician, any and all information they may require concerning my case. I understand and agree that I am responsible for any and all charges not covered by my insurance company. I further understand that I am responsible for all collections and/or attorney fees necessary to collect this debt. Once the account is turned over to a collection agency, a fee of 30% of the balance due will be added to the total. I authorize the doctors and staff of Laster Eye Center to examine my eyes and perform any services normally associated with an eye examination.
