Office Policies. E-mail data may be unsecured and result in health information being distributed to unknown third parties for which EFM is not responsible. Use of the secured patient portal is the preferred route of communication for routine matters. Phone call is the preferred route of communication for urgent matters. EFM does not provide emergency care. There may be times when Dr. Black is unavailable. If a health matter is urgent I agree to seek care at an urgent care or emergency room. The preferred urgent care for Empower Family Medicine is Urgent Care at Druid Hills 0000 X Xxxxx Xxxxx Xx XX Xxxxx X, Xxxxxxx, XX 00000. All prescription refills for chronic medications should be requested at office visits. Routine refills will not be issued by phone, fax or call. For Principal and Patients: I have reviewed the EFM Patient Agreement, Policies and Privacy Practices. I have been given ample time to ask questions regarding its content, and consent to its terms. This agreement is made voluntarily with no urgent medical care need. I understand that these authorizations take effect while Patient is enrolled with Empower Family Medicine, and that Patients or Principals have the right to revoke such authorization at any time by cancellation of the Monthly Enrollment Fee, or by written or verbal request. Patient: Principal: Medical Director: Xxxxxxx Xxxxx M.D. MEDICARE OPT OUT AGREEMENT This agreement ("Agreement") is entered into by and between Empower Family Medicine, LLC, a Georgia professional corporation, owned and operated by Dr. Xxxxxxx Xxxxx, MD, (the "Physician"), whose principal medical office is located at 000X Xxxxxxx Xxx Xxxxx 000 Xxxxxxx, XX 00000, and , a beneficiary enrolled in Medicare Part B ("Beneficiary"), who resides at .
Office Policies a. Appointments and Cancellations. Appointments will ordinarily be 50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice (1 business day). If you miss a session without canceling, or cancel with less than 24 hour notice (1 business day), my policy is to collect the amount of the full session. If there is an emergency or illness, please contact me so we can discuss it. In addition, you are responsible for coming to your session on time. If you are late, your appointment will still need to end on time and you will still be charged the full cost of the session. If I am running late, I will do my best to give you a full session. If I am unable to do so, then a prorated amount of my hourly rate of $130 will be charged. _____ I understand that sessions must be cancelled 1 business day (24 hours) in advance or there will be a charge of $130. (Please initial.)
Office Policies. The appointment times are reserved exclusively for you. Please consider your appointment card as your confirmation. We understand that conflicts in schedules sometimes arise. If that is the case, we ask that you give us a 48 business hour notice so we can use that valuable time for patients who may be in need. We hope that you will help us in this issue so we can better serve you and our other patients. A
Office Policies. Appointments Please understand that we reserve time just for you when you make an appointment with us and we know your time is very important. We will do everything in our power to have you in-and-out on time. Likewise, we ask that you respect our time, and the time of other patients. If you are scheduled for an appointment and need to reschedule or cancel, we require 48 hours notice. Without this notice, we are unable to offer treatment to other patients that may have needed our care. A $50 fee may be charged to you for any appointment that rescheduled, cancelled or missed without 48 hours notice. For any missed appointment fees collected, Xxxxxx Xxxxxx Healthcare will match the fee and donate the total amount to the charity Xx Xxxxxx has chosen for the quarter. If you are late for your appointment, we may not be able to accommodate you. If you think that you will be late, we do ask that you call as soon as possible so that we may advise you if your late arrival can be accommodated, or if we will need to reschedule you. You may be required to pre-pay for your next appointment if you have an outstanding balance or if you have missed two or more appointments in the last twelve months. For services exceeding $1000 that will have multiple visits, half of your anticipated patient responsibility is due at your first visit or at the time your appointment is made. The remainder is due before being seen for your final visit. For services exceeding $1000 that are only one visit, your full patient responsibility is due at the time of service. Patients Under the Age of 18 Xxxxxx Dental Helathcare is a child friendly practice and we strive to provide an upbeat and comfortable office environment. We ask that you allow your child to accompany our staff through the dental experience. We are all experienced in helping children overcome anxiety and do not want children to have negative dental experiences. Studies and experience have shown that most children over the age of 3 react more positively when permitted to experience the dental visit on their own. Some children may need to seek treatment from a pediatric dentist. Appropriate referrals will be made with the consent of parents. We kindly ask that you refrain from bringing small children to your dental appointment. Children can interfere with our ability to provide you with timely and comprehensive dental care. Children who accompany a parent cannot be brought into the treatment room during your treatment due to x...
Office Policies. APPOINTMENTS/COMMUNICATIONS: Xx. Xxxxxx can be reached at 000-000-0000 to schedule an appointment or for other inquiries. At times, Xx. Xxxxxx may be in session with a client and unable to answer the telephone. If this should occur, please leave a message on our confidential voicemail. Your call will be returned promptly. Please note that email is not a secure form of communication and does not ensure confidentiality. Therefore, we request that it only be used for non-clinical communication (e.g. scheduling appointments, etc.) MISSED APPOINTMENTS/LATE CANCELLATIONS: When you schedule an appointment, the time is reserved specifically for you. If you are unable to keep the appointment or need to reschedule, please do so as soon as possible. Appointments cancelled without at least 48 hours notice may be charged a Missed Appointment/Late Cancellation Fee of $50. Insurance companies do not provide reimbursement for these fees. EMERGENCY SERVICES: We do not provide emergency services. If you are experiencing a life-threatening emergency, please call 911, go to your local emergency room or follow emergency procedures per your insurance carrier.
Office Policies. Welcome to All Care Dental! We are excited to have you as our lifelong patient! It is our goal to provide you with the highest quality dentistry and care possible in a courteous and efficient manner. In order to achieve this goal, we ask that you read and agree to the following office policies:
Office Policies. Welcome to Dental Spa of West Covina! We are excited to have you as our lifelong patient! It is our goal to provide you with the highest quality dentistry and care possible in a courteous and efficient manner. In order to achieve this goal, we ask that you read and agree to the following office policies:
Office Policies. Xx. XxXxxxxxx is committed to providing a welcoming environment for her patients. Your time is valuable as is that of all the families served by this practice. The following policies are designed to improve everyone’s patient experience: Please arrive on time for your visit. Other patients have appointments after yours and thus families that arrive more than 10 minutes late may be asked to reschedule the visit. If you cannot make the appointment, please call more than ONE office business day ahead of time to reschedule. Last minute cancellations and no-shows may be charged a fee. Reminder calls are made as a courtesy only. It is your responsibility to know the time and date of your appointment. Tests (labs and X rays) may be requested prior to the appointment. Please ensure you have the test done on time so the results can be reviewed with you at your upcoming appointment. The due date is indicated on your visit summary and test order sheet. You may be asked to reschedule if the results are not available in time or if the tests have not been obtained. Patients who miss more than 3 appointments may be asked to continue their care with another practice. Please have your medication list ready for review during office visits. Please contact your pharmacy for all prescription refill requests. Please allow at least 2-3 business days for processing. Prescription refills require regular office visits. To ensure you or your child’s safety, a regular evaluation of the condition and medication interactions is required. If you are transferring care from another provider or center, please ensure that all previous clinic notes have been sent BEFORE the scheduled appointment.
Office Policies. Sessions and Fees • After the initial visit, sessions are typically 50-55 minutes, which includes time for scheduling, payment, and therapy. The fee is $125.00 per session. • If I am an in-network provider for your insurance, you may owe a co-pay or the full contracted fee as determined by your insurance plan. • In general, I do not offer 30-minute psychotherapy sessions. On occasion, we may agree to utilize 30-minute session as appropriate. The fee for this service is $80. • As a rule, I do not conduct phone therapy. However, I am available for phone consultations in urgent situations. Calls lasting longer than 15 minutes will be charged a fee proportional to my hourly rate. • You are asked to provide me with your most current contact information at all times so that you may be reached about scheduling, payment issues, or emergencies. • A $40 fee will be charged for all returned checks. • A collection agency may be notified if a balance becomes 90 days past due. In this situation, only information related to billing will be released. • I do not practice forensic psychology and do not conduct forensic evaluations. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my related time and expenses, includ- ing preparation, report writing, copy costs, professional consultation, transportation, time needed to reschedule patient appointments and other professional meetings, as well as the entire time spent away from my office. This applies even if I am called to testify by another party. Due to the difficulties involved in legal matters, I charge $300.00 per hour with a minimum engagement of three hours to be paid as an advance retainer. Additionally, for any legal proceedings that require me to be away from my office, I require an advance retainer of $900 and at least 72-hours advance notice due to the time needed to reschedule patient appointments. In the event that my participation in legal proceedings has been scheduled but needs to be cancelled, I require at least 48-hours notice. Failure to provide at least 48-hours notice of cancellation will result in your forfeiture of the $900 retainer fee. • Firearms are strictly prohibited in my office suite. Availability • I am available for regularly scheduled appointment times. Dates of vacations and other exceptions will be provided in advance whenever possible. During times that I will be out of town or difficult to reach, I may ask another therapist t...
Office Policies. Unless otherwise noted, this process is voluntary. You may at any time withdraw from the process. During your course of treatment, please provide me with feedback. If a client feels a lack of direction, it may become evident through a lack of progress or withdrawal in other ways, such as missed appointments or ending therapy altogether. The only way I can tell if therapy is helpful to you is through your own voice. • Hourly appointments are 53 minutes long and are usually scheduled for once a week. Longer sessions may be accommodated, agreed upon by you and I in advance.
