B – Name and Address of Responsible Party

C – Credit Card Information

D – Make checks payable to Summit Medical Group

E – Website

F – Amount now due from responsible party. Includes non-covered, deductibles and co-insurance

G – Date of Service

H – Provider of Service

I – Description of the services rendered

J – Amount charged

K – Amount of Insurance Payment

L – Adjustments

M – Patient Payments

N – Amount you owe

O – Pending Patient Balance

P – Account Inquiry Phone Number

Q – Amount now due from responsible party.