Welcome to Urgent Care in Santa Monica, CA - Get Urgent Care by a top trained physician, your health is our priority
1-866 697 0402
2021 Santa Monica, P.O. Box: Suite 710E Santa Monica, CA 90404 USA
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We are open Monday to Friday 8 am to 5 pm

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Health Care Authorization Form






Specific AuthorizationsI give permission to Urgent-Care on Wheels/ USMDDirect.com to verify my insurance, use my address, phone number, and clinical records to contact me with appointment reminders and missed appointments.

Post my testimonialDisplay patient photographSend me a newsletterSend a birthday card or holiday related cards information about treatment alternatives or other health related information.
If.Urgent-Care on Wheels/ USMDDirect.com contacts me by phone, I give them permission to leave a phone message on my answering machine or voice mail

I give Urgent-Care on Wheels/ USMDDirect.com to treat me in an open room where other patients are also being treated. I am aware that other persons in the office may overhear some of my protected health information during the course of care. Should I need to speak with the doctor at any time in private, the doctor will provide a room for these conversations.

The authorization is requested by.Urgent-Care on Wheels/ USMDDirect.com for its own use/disclosure of PHI. (Minimum standards apply)
You have the right to refuse to sign this AUTHORIZATION. If you refuse to sign this AUTHORIZATION,Urgent-Care on Wheels/ USMDDirect.com will not refuse to provide treatment




Payment Options

Service Charge : $99 + PPO insurance

Cash Price : $225

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