Missed Appointment Fees. I understand that there is a $25.00 fee for any missed “non-procedure” appointments. There is a $50.00 fee for any missed “procedure” appointments.
Missed Appointment Fees. A missed appointment fee will be charged to your card on file at the end of the business day when your missed appointment occurred. Appointments are considered missed if you do not show up for your appointment or reschedule less than 24 hours prior to your appointment according to the following schedule: First Missed Appointment: $50.00 Second Missed Appointment: Your contracted insurance rate or $100.00 for self-pay clients Third Missed Appointment: $150.00 Your time is valuable to us, so we strive to run on time and will never double-book your appointment. Therefore, arriving more than 15 minutes late for your appointment will result in an abbreviated visit or the need to reschedule so that we can stay on time for patients with appointments after yours. The missed appointment fee will be charged if we need to reschedule your appointment due to your late arrival. Deductibles/Co-Insurance/Non-Covered Charges: After your insurance company processes our claim they will send you and us an Explanation of Benefits (EOB). This EOB will indicate any fees for which you are responsible (i.e. deductibles and co-insurance). We will automatically charge your card for these fees. If you have questions we are happy to discuss them with you. I have read and agree to the above terms. Patient Name: Signature: Date: NOTE: Once entered into our triple-encrypted, password-protected accounting system, this portion of the form is shred for security purposes. Name on card: Card Number: Visa or MasterCard Only Expiration Date: CVV: Zip Code: Patient Information: NAME: First Middle Last ADDRESS: Street City State Zip PHONE: Home Work Cell Can a message be left at Home? Yes No Work? Yes No Cell? Yes No SEX: Male Female MARITAL STATUS: S M D W DATE OF BIRTH: _ AGE: EMPLOYER: POSITION: REFERRED BY: May I contact this person? Yes No May I send reports and/or office notes to your referring physician? Yes No Have you been in therapy before? Yes No For your current problem? Yes No If so, Where? When?
Missed Appointment Fees. Patients who fail to keep an appointment will be rescheduled once upon request: No Charge • After a second and subsequent missed appointment: $25 fee billed to your account • Third missed appointment: Possible discharge from our practice Patient Name:
Missed Appointment Fees. Because other patients may be in need of in-person and online appointments, proper advanced notice should be given to the office about a cancellation. Patient agrees to give a 12-hour notice of a need to cancel an appointment.
Missed Appointment Fees. While we strive for regular attendance, we understand that children get sick and situations arise which will result in the need to cancel your appointment. Please do us the courtesy of giving us as much notice as is possible. Sessions cancelled within 2 hours may be subject to a no-call / no-show fee. Sessions missed without notification will be billed the no-call / no-show fee of $25.00. Payment for this fee will be required prior to your next scheduled therapy session. I read, understand, and agree to comply with the Payment Agreement of Speech and Occupational Specialists, LLC. Patient’s Name: Parent’s Printed Name:
Missed Appointment Fees. I understand that there is a $25.00 fee for any missed “non-procedure” appointments. There is a $50.00 fee for any missed “procedure” appointments. Xx. Xxxx feels that a patient presenting to our office with sinus, allergy, throat or voice complaints require a thorough examination of that specific area. In some cases, this can only be accomplished through the use of an endoscope. This examination is essentially painless and, in many cases, can be accomplished quickly. A “procedural fee” will be submitted to your insurance carrier for this procedure. In most cases, we will accept your insurance company’s allowance for this procedure. You will be obligated to pay only any deductible and/or co-payments that are applied to this claim. (Please note, some insurance companies may list this diagnostic procedure as “surgery” on the insurance remittance advice you receive.) These procedures have almost no risk and provide your physician with an excellent view of the areas involved. Please sign below to acknowledge that you have read the above and agree to undergo this procedure. 24 hour notice is required for any cancellation to avoid being charged the above noted fees. I understand it is my responsibility to notify Xxxx Arundel Ear Nose and Throat if my insurance has changed. If I fail to do so in a timely manner and my insurance fails to process my claim for payment due to the timely filing restrictions, I will be financially responsible for the visit cost in full. Any patients arriving more than 15 minutes late to their appointment, without prior notice to our office, will result in the forfeit of their appointment time. Your appointment will be rescheduled at the next available opening, which is not guaranteed to be the same day. I have read and fully understand this Financial Agreement. I acknowledge copays are due at the time of my visit and that I will be charged for any missed appointments, along with any and all financial balances left by my insurance. If any balances remain open and it is necessary to refer the account for collection, I agree to be responsible for all costs of collection including attorney fees of twenty-five (25%) of any balance due. I have read and fully understand this financial agreement. I acknowledge co-pays are due at the time of my visit and that I will be charged for any missed appointments, along with any and all financial balances left by my insurance company.
Missed Appointment Fees. I understand that there is a 2 BUSINESS DAY requirement to cancel or re-schedule an appointment. Failure to do so may result in a non-refundable missed appointment fee. Furthermore, if you miss your appointment, you will be assessed a fee. Our fees are as outlined below. • $25 fee for all “non-procedure” appointments. • $50 fee for all “procedural” appointments, such as a videostrobe appointment. • Cosmetic treatments will loose the deposit made. The amount varies and specific to the cosmetic treatment you are scheduled for. • $50 fee for all Groupon clients. For multi-treatment services, a treatment will be deducted from your series purchased. I agree and understand to the terms as stated above. I understand that the fee is non-refundable and will not be applied towards the cost of any future appointments and/or treatments.
Missed Appointment Fees. If Company schedules an appointment with Customer to deliver or install Products or Services, Customer or its authorized representative must be available at Customer’s location for the scheduled appointment date and time to grant Company access or to accept delivery of the Products or Services, or to work with Company’s technician to activate Service. If Customer fails to have an authorized representative available at the scheduled appointment time, Company’s technician will attempt to contact Customer or its authorized representative by phone for up to fifteen (15) minutes after which time the appointment may be rescheduled. Company reserves the right to charge Customer a reasonable appointment rescheduling fee. Such appointment rescheduling fee must be paid before the appointment is rescheduled.
Missed Appointment Fees. There will be a $30.00 fee for any Chiropractic or Nutrition appointments missed without notice. Missed appointments for Massage and Acupuncture will be charged the full amount of the appointment. We understand that you might not be able to keep an appointment, but we ask that you please provide us 24-‐hour notice for any change or cancellations. I have read this correspondence authorization form, and give authorization for Firestone Chiropractic & Wellness to xxxx me for any missed appointments that did not have proper notice. Signature:
