Common use of Missed Appointments Clause in Contracts

Missed Appointments. In the event that you are unable to keep a scheduled appointment, it is your responsibility to notify me with no less than 24-hour notice or you will be liable for the full session fee of $160. If your appointment is scheduled for a Monday, you must cancel before Sunday or the $160 fee applies. I collect payment and schedule your next appointment at the end of our 50-minute session. My fees for sessions and services are: • 50-minute Session $160 • Letter Writing on your behalf $90/30 minutes or $160/50 minutes. • Missed Appointment Fee Full Session Fee of scheduled session. • Cancellation less than 24-hour Full Session Fee of scheduled session. • Telephone Consult with you or With a third party (MD, Psychiatrist, Other therapist, case worker, etc…) No charge for first 10 minutes $60/15 minutes after. • Outside of session reading reports Assessments or other documents You or a third party send me. No charge for 10 minutes, $60/15 minutes thereafter. • Returned Check Fee $35 or Bank Fee if higher. Payment: You agree to pay the session fee in full at the end of each session as well as any other fees that are outstanding before another session may be scheduled. I accept a personal check, cash or Venmo only. Please have the exact amount as I will not be able to provide change. No credit cards are accepted. Checks are made out to: Xxxxxx X. Xxxxxx, MS, LPC. Client Signature: Date: Page 2 of 2-Fees and Financial Agreement Insurance: I do not work with insurance companies. Insurance companies require a client be assigned a mental health disorder diagnosis in or to be reimbursed for counseling services. This mental health disorder designation becomes part of your permanent health record and can be accessed by current and future employers, the insurance industry and other such entities that deem it necessary to have your personal health record. If you want to assume the risk, I will provide you a receipt that you may submit for possible reimbursement as an out-of-pocket provider if that benefit is part of your plan. I do not call or correspond with your insurance company or provide additional paperwork other than a receipt. You are responsible for payment in full at the end of each scheduled session. Agreement: By signing below, you indicate that you have read, understand and agree to the terms and conditions outlined in this Financial Agreement document (2 pages). Your signature also indicates that you have had the opportunity to ask questions and/or discuss any concerns with me in the first, intake, session. Client Name (Print):

Missed Appointments. In the event that you are unable to keep a scheduled appointment, it is your responsibility to notify me with no less than 24-hour notice or you will be liable for the full session fee of $160150. If your appointment is scheduled for a Monday, you must cancel before Sunday or the $160 150 fee applies. I collect payment and schedule your next appointment at the end of our 50-minute session. My fees for sessions and services are: • 50-minute Session $160 150 • Letter Writing on your behalf $90/30 minutes or $160/50 150/50 minutes. • Missed Appointment Fee Full Session Fee of scheduled session. • Cancellation less than 24-hour Full Session Fee of scheduled session. • Telephone Consult with you or With a third party (MD, Psychiatrist, Other therapist, case worker, etc…) No charge for first 10 minutes $60/15 minutes after. • Outside of session reading reports Assessments or other documents You or a third party send me. No charge for 10 minutes, $60/15 minutes thereafter. • Returned Check Fee $35 or Bank Fee if higher. Payment: You agree to pay the session fee in full at the end of each session as well as any other fees that are outstanding before another session may be scheduled. I accept a personal check, cash or Venmo only. Please have the exact amount as I will not be able to provide change. No credit cards are accepted. Checks are made out to: Xxxxxx X. Xxxxxx, MS, LPC. Client Signature: Date: Page 2 of 2-Fees and Financial Agreement Insurance: I do not work with insurance companies, except BCBS of NC. Insurance companies require a client be assigned a mental health disorder diagnosis in or to be reimbursed for counseling services. This mental health disorder designation becomes part of your permanent health record and can be accessed by current and future employers, the insurance industry and other such entities that deem it necessary to have your personal health record. If you want to assume the risk, I will provide you a receipt that you may submit for possible reimbursement as an out-of-pocket provider if that benefit is part of your plan. I do not call or correspond with your insurance company or provide additional paperwork other than a receipt. You are responsible for payment in full at the end of each scheduled session. Agreement: By signing below, you indicate that you have read, understand and agree to the terms and conditions outlined in this Financial Agreement document (2 pages). Your signature also indicates that you have had the opportunity to ask questions and/or discuss any concerns with me in the first, intake, session. Client Name (Print):.

Missed Appointments. In the event that If I do not hear from you are unable after a missed appointment and have reason for concern, I may reach out to keep your identified emergency contact to ensure your well-being. If you do not show up for an appointment this will be considered a scheduled appointment, it is your responsibility to notify me with no less than 24no-hour notice or show and you will be liable for charged the full session missed appointment fee of $16050.00 Two no shows in a row, may require us to dis- continue treatment. Late appointments: All sessions begin at the scheduled time and last 53 minutes. If you arrive late, we will meet until 53 minutes after your appointment is scheduled for a Mondaysession time. Please note that multiple missed/cancelled appointments and late arrivals may require us to discontinue treatment. In this circumstance, you must cancel before Sunday or the $160 fee applies. I collect payment and schedule your next appointment at the end of our 50-minute session. My fees for sessions and services are: • 50-minute Session $160 • Letter Writing on your behalf $90/30 minutes or $160/50 minutes. • Missed Appointment Fee Full Session Fee of scheduled session. • Cancellation less than 24-hour Full Session Fee of scheduled session. • Telephone Consult will discuss with you in person or With a third party (MD, Psychiatrist, Other therapist, case worker, etc…) No charge for first 10 minutes $60/15 minutes afterby phone how we should proceed. • Outside of session reading reports Assessments or other documents You or a third party send me. No charge for 10 minutes, $60/15 minutes thereafter. • Returned Check Fee $35 or Bank Fee if higher. Payment: You agree to pay the session fee in full at At the end of each session as well as any other fees that are outstanding before another we will make sure to have the following session may be scheduled. I accept You should receive a personal check, cash or Venmo only48 e-mail reminder and 24 hour text reminder about your scheduled appoint- ments. Please have the exact amount as I will not be able to provide change. No credit cards are accepted. Checks are made out to: Xxxxxx X. Xxxxxx, MS, LPC. Client Signature: Date: Page 2 of 2-Fees EAP”s and Financial Agreement Insurance: I Medicaid do not work with insurance companiesallow charges for missed sessions or cancelled session. Insurance companies require Therefore if you are using EAP or Medicaid you will be allowed ONE less than 24 hour cancellation or missed appointment. In Summary: A credit card will be kept on file. (I use Ivy Pay, which is a client HIPPA compliant secure site). On the third less than 24 hour cancellation in a year, your card will be assigned a mental health disorder diagnosis in or to be reimbursed for counseling services. This mental health disorder designation becomes part of your permanent health record and can be accessed by current and future employers, the insurance industry and other such entities that deem it necessary to have your personal health recordcharged $50.00. If you want miss your appointment and do not call me before the appointment your card will be charged $50.00. Medicaid and EAP clients cannot be charged. If you are using Medicaid as a primary in- surance or an EAP, you are allowed one less than 24 hour cancellation and one missed appointment. If you have any questions or are unclear, please do not hesitate to assume contact me. Please initial indicating you have read and understood the riskterms of the attendance policy. Communication: The most secure form of communication is by phone or voicemail. I have a secure voice mail, 000 000-0000 and a secure e-mailI; xxxxxxx@xxxxxxxxxxxxxxxxxxx.xxx. if you need to reach me outside of your session time, I encourage you to call my office number 000 000-0000. If you are distressed and feel the need to call me outside of our regular meeting time, please know that I am only available via phone from 9-6. I will provide you return your call within 24 hours. E-mail and phone are usually for scheduling, outside homework or business related is- sues and not intended to replace a receipt that you may submit therapy sessions. Social Media I maintain multiple social media accounts for possible reimbursement my practice. These accounts serve to promote my services and offer encouragement and resources. They are not a substitute for treatment by a licensed mental health professional and nothing shared should be interpreted as an out-of-pocket provider if that benefit is part of your plana personal message. I do not call or correspond interact with clients via social media. I also do not expect you to follow any of my ac- counts based on our work together. If you choose to follow one of my accounts and do reach out to me via that method, we will discuss that further in our next session. I may remove your insurance company or provide additional paperwork other than a receiptcom- munication/comment/message from my account if I feel it violates your confidentiality. Please initial indicating you have read and understood the terms of the communi- cations police. Payment: I require payment at the beginning of each session. You are responsible for payment in full at the end of each scheduled session. Agreement: By signing belowmay pay via cash, you indicate that you have read, understand and agree to the terms and conditions outlined in this Financial Agreement document (2 pages). Your signature also indicates that you have had the opportunity to ask questions and/or discuss any concerns with me in the first, intake, session. Client Name (Print):check or credit card.

Missed Appointments. In We understand that unforeseen events happen that may prevent a patient from making his/her appointment; however patients will be charged a non-refundable $25.00 no-show fee after his/her second missed appointment. To avoid this fee, kindly call 24 hours prior and cancel or reschedule any appointment(s). As a courtesy, patients will receive a reminder phone call from our office the event that business day prior to his/her appointment. I have read the Patient Financial Policy and agree to abide by its terms. I authorize my insurance company to forward the Explanation of Benefits (EOB) and related payments to Xxxxxx X. Xxxx, M.D. Patient Signature Date INTERNAL MEDICINE GROUP OF TAMPA BAY ID# ***UPDATED OFFICE POLICIES*** Effective January 1, 2014 As part of our ongoing efforts to make your experience with us a pleasant one, and to ensure your continued satisfaction with our services, we have adopted some additional office policies. Please read carefully, and initial the following updates. Feel free to speak with our staff should you are unable to keep have any questions or concerns about these policies. Blood work is required before all physical exams. If a scheduled patient misses a pre- physical blood work appointment, it is your responsibility their physical exam will be canceled, and will need to notify me with be rescheduled. Payment for any required insurance co-pay, self-pay charge, and/or any outstanding balance on a patient’s account will be required at time of visit. A $25.00 non refundable no less than 24-show fee will be applied to the patient’s account for an appointment missed without a 24 hour notice to cancel. This fee is not covered by insurance. It is the sole responsibility of the patient. As a consideration to other patients, patients who are 20 minutes or you more late for their appointment will be liable rescheduled to another time. All prescription requests require a minimum 24 hour turnaround time for the full session fee of $160processing. If Thank you for your appointment is scheduled for a Monday, you must cancel before Sunday or the $160 fee appliescooperation. I collect payment and schedule We look forward to your next appointment at the end of our 50-minute sessioncontinued care with us. My fees for sessions and services arePatient’s Name: • 50-minute Session $160 • Letter Writing on your behalf $90/30 minutes or $160/50 minutes. • Missed Appointment Fee Full Session Fee of scheduled session. • Cancellation less than 24-hour Full Session Fee of scheduled session. • Telephone Consult with you or With a third party (MD, Psychiatrist, Other therapist, case worker, etc…) No charge for first 10 minutes $60/15 minutes after. • Outside of session reading reports Assessments or other documents You or a third party send me. No charge for 10 minutes, $60/15 minutes thereafter. • Returned Check Fee $35 or Bank Fee if higher. Payment: You agree to pay the session fee in full at the end of each session as well as any other fees that are outstanding before another session may be scheduled. I accept a personal check, cash or Venmo only. Please have the exact amount as I will not be able to provide change. No credit cards are accepted. Checks are made out to: Xxxxxx X. Xxxxxx, MS, LPC. Client Patient’s Signature: Date: Page 2 Witness Signature: Date: _ INTERNAL MEDICINE GROUP OF TAMPA BAY ***INSURANCE COVERAGE NOTICE*** I, understand that the following may not be covered by my insurance; laboratory testing, including but not limited to Labcorp, Quest Diagnostics, ECG/EKG, vaccinations, and/or injection therapy. I understand I will be responsible for 100% of 2the billed cost for any of the above tests/procedures not covered by my insurance. I also understand that it is my responsibility as the patient, and the policy holder to contact my insurance company to inquire as to what services are covered. I also understand that any lab work done at INTERNAL MEDICINE GROUP OF TAMPA BAY invoice(s) I receive for lab fees are from the lab directly, therefore all billing issues need to be addressed with the lab directly. I as a patient of Internal Medicine Group of Tampa Bay understand that my physical exam must be scheduled a year and a day from my last physical in order for the exam to be covered by insurance. I also understand that it is my responsibility to confirm the date of my last physical exam before scheduling. If my appointment is scheduled before the one year and one day required by my insurance, I understand that I will be financially responsible for the appointment and all services provided. _____________________________________________________ _________________ Patient Signature Date Witness Signature Date 00000 Xxxxx Xxxxx Xxxx Xxxxx X Xxxxx, XX 00000 Phone: (000) 000-Fees 0000 Fax: (000) 000-0000 INTERNAL MEDICINE GROUP OF TAMPA BAY *PERMISSION TO RELEASE PROTECTED MEDICAL INFORMATION* The doctor and Financial Agreement Insurancestaff at INTERNAL MEDICINE GROUP OF TAMPA BAY cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below the names(s) of the individual(s) you authorize our office to discuss your care with. Your PHI will be disclosed to the individual(s) listed below until you notify us otherwise in writing. This authorization will remain in effect for one year unless otherwise specified. I understand by signing this form I authorize the release of all medical records, which may include psychiatric information, genetic counseling (Acquired Immunodeficiency Syndrome), and/or may include the result of an HIV test. I understand that my (PHI) may be used or disclosed under this authorization, and may be subject to re-disclosure, thus my PHI may no longer be protected by law. By signing this authorization I expressly consent to the release of information as designated above. I understand I must notify INTERNAL MEDICNE GROUP OF TAMPA BAY, in writing, where the original authorization is retained, in order to discontinue this consent to release. I, give my permission for the following person (s) to receive my medical information. Name: Relationship: Signature Date INTERNAL MEDICNE GROUP OF TAMPA BAY I, authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to contact me by home phone, cell phone, fax, and/or email, and leave detailed messages regarding all test results, and/or reminders for future scheduled appointments. Patient Home Phone # Patient Cell Phone # Patient Private Fax # Patient email address If there are any changes to the contact information previously provided to INTERNAL MEDICINE GROUP OF TAMPA BAY I understand that it is my responsibility to provide timely updates to my contact information on file. If I wish to update any information, or revoke permission for messages to be left regarding test results, I must contact INTERNAL MEDICINE GROUP OF TAMPA BAY in writing during normal business hours. Please initial below to indicate your authorization Yes I authorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. No I do not work with insurance companiesauthorize INTERNAL MEDICINE GROUP OF TAMPA BAY to leave messages. Insurance companies require a client be assigned a mental health disorder diagnosis in Signature Date Print Name INTERNAL MEDICINE GROUP OF TAMPA BAY PRIVACY NOTICE Effective January 1, 2014 A copy of INTERNAL MEDICINE GROUP OF TAMPA BAY'S Privacy Practices is available at xxx.xxxxxxxxxxx.xxx or at our office. Acknowledgment of receipt of Notice of Privacy Practices: I, have received notice of Privacy Practices from INTERNAL MEDICINE GROUP OF TAMPA BAY which has been updated for the new Omnibus Rule and has an effective date of September 23, 2013. We encourage you to be reimbursed for counseling servicesreview it carefully. This mental health disorder designation becomes part Our notice of your permanent health record and can be accessed by current and future employers, the insurance industry and other such entities that deem it necessary Privacy Practices is subject to have your personal health recordchange. If you want to assume the riskwe change our Notice, I will provide you a receipt that you may submit obtain a copy at the front desk. The notice describes: • the ways the Privacy Rule allows our practice to use and disclose protected health information. How our practice will get your permission, or authorization, before using your health records for possible reimbursement as an out-of-pocket provider any other reason. • the practice's duties to protect health information privacy. • the patient's privacy rights, including the right to complain to HHS and to the covered entity if that benefit is part of you believe your planprivacy rights have been violated. • how to contact our practice for more information and to make a complaint. I do not call or correspond with your insurance company or provide additional paperwork other than a receipt. You are responsible for payment in full at understand that the end of each scheduled session. Agreement: By signing below, you indicate Privacy Practices may be revised from time to time and that you I have read, understand and agree the right to the terms and conditions outlined in this Financial Agreement document (2 pages). Your signature also indicates that you have had the opportunity to ask questions and/or discuss any concerns with me in the first, intake, session. Client Name (Print):receive an updated copy upon request.