CLARK E. SMITH, M.D., D.F.A.P.A. 9820 WILLOW CREEK ROAD, SUITE 295, SAN DIEGO, CA 92131 (858) 530-9112
INSURANCE INFORMATION AND PAYMENTS: I hereby authorize my insurance company to make payment of benefits directly to CLARK E. SMITH, M.D., for services rendered. I authorize CLARK E. SMITH, M.D., to release any information requested by the insurance company to process my claims.
FINANCIAL RESPONSIBILITY: I acknowledge that I am responsible for payment of all professional services rendered. I understand that my insurance carrier may be billed as a courtesy and I am responsible for that which my insurance does not cover. I acknowledge that I will be charged a no-show fee that is equal to the cost of my visit if I no-show to my scheduled appointment or fail to cancel with at least 24-hour notice. I acknowledge that payments are due and payable within 30 days and that failure to make a monthly payment toward my balance will result in a $10 service charge. I also understand that my name may be submitted to collection agency should I fail to make payments on my account as requested unless other arrangements are made.