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

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