INSURED’S OR AUTHORIZED PERSON’S SIGNATURE. UPON CONFIRMATION OF APPOINTMENT. A NO-SHOW fee of $25.00 per missed appointment will be due the day of the scheduled appointment. I authorize direct payment of medical nutrition therapy benefits to Araceli Vazquez, MS, RD, LD for services rendered; and authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment. I certify that the above information given by me is correct. I understand that I am financially responsible for any balance not covered by my insurance. I understand that the above provided information may be used in any collection efforts of past due balances.