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I agree I hereby authorize payment of the vision benefits to be responsible for all charges for vision services and materials otherwise payable to me directly to the below no paid by my vision benefit plan unless the treating vision provider/ named vision provider/practice. I. N or Social Security Number Provider s Signature Telephone Address City State Mail Completed Claim forms to Colonial HealthCare Inc. Zip. Practice has a contractual agreement with my plan prohibiting all or a portion of...
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