Common use of MISSED OR CANCELLED APPOINTMENTS Clause in Contracts

MISSED OR CANCELLED APPOINTMENTS. Office and/or telemedicine visits are by appointment only. All administrative and billing matters, including copayment and completion of any forms, are expected to be completed before the time of your appointment. Patients are asked to arrive 15 minutes before the scheduled appointment time in order to complete the check-in process. Patients arriving more than 20 minutes late may be required to reschedule their appointment for the next available opening consistent with the type of appointment requested. Please look carefully over pages 4-11 of this document, then initial each statement. I, the undersigned, agree that I: have reviewed and agree with the Notice of Privacy Practices & Patient Rights (pages 4-5) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 6-7) have reviewed and agree with the Consent to Bill and Release Medical Information to Insurance Company (page 8) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 9-10) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 11) I, the undersigned, herby certify that I have provided correct information about the patient during registration. I understand that any false statements or concealment of material fact may be prosecuted under applicable federal and state laws. I certify that I have read, fully understand, and accept the above information, terms, and conditions. I, the undersigned, further certify that I am legally authorized as the patient, or as the patient’s parent or legal guardian, to execute the above and to accept its terms. PATIENT NAME OR NAME OF DATE PARENT/ LEGAL GUARDIAN (PRINTED) PATIENT SIGNATURE OR DATE PARENT/ LEGAL GUARDIAN SIGNATURE PATIENT PREFERRED NAME PATIENT DATE OF BIRTH

MISSED OR CANCELLED APPOINTMENTS. Office and/or telemedicine visits are by appointment only. All administrative and billing matters, including copayment and completion of any forms, are expected to be completed before the time of your appointment. Patients are asked to arrive 15 minutes before the scheduled appointment time in order to complete the check-in process. Patients arriving more than 20 minutes late may be required to reschedule their appointment for the next available opening consistent with the type of appointment requested. Please look carefully over pages 43-11 10 of this document, then initial each statement. I, the undersigned, agree that I: have reviewed and agree with the Notice of Privacy Practices & Patient Rights (pages 3-4-5) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 5-6-7) have reviewed and agree with the Consent to Bill Xxxx and Release Medical Information to Insurance Company (page 8) 7) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 8-9-10) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 1110) I, the undersigned, herby certify that I have provided correct information about the patient during registration. I understand that any false statements or concealment of material fact may be prosecuted under applicable federal and state laws. I certify that I have read, fully understand, and accept the above information, terms, and conditions. I, the undersigned, further certify that I am legally authorized as the patient, or as the patient’s parent or legal guardian, to execute the above and to accept its terms. PATIENT NAME OR NAME OF DATE PARENT/ LEGAL GUARDIAN (PRINTED) PATIENT SIGNATURE OR DATE PARENT/ LEGAL GUARDIAN SIGNATURE PATIENT PREFERRED NAME PATIENT DATE OF BIRTHBIRTH Notice of Privacy Practices & Patient Rights This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully and direct any questions to your provider or other Gladstone staff.

MISSED OR CANCELLED APPOINTMENTS. Office and/or telemedicine visits are by appointment only. All administrative and billing matters, including copayment and completion of any forms, are expected to be completed before the time of your appointment. Patients are asked to arrive 15 minutes before the scheduled appointment time in order to complete the check-in process. Patients arriving more than 20 minutes late may be required to reschedule their appointment for the next available opening consistent with the type of appointment requested. Please look carefully over pages 4-11 of this document, then initial each statement. I, the undersigned, agree that I: have reviewed and agree with the Notice of Privacy Practices & Patient Rights (pages 4-5) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 6-7) have reviewed and agree with the Consent to Bill Xxxx and Release Medical Information to Insurance Company (page 8) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 9-10) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 11) I, the undersigned, herby certify that I have provided correct information about the patient during registration. I understand that any false statements or concealment of material fact may be prosecuted under applicable federal and state laws. I certify that I have read, fully understand, and accept the above information, terms, and conditions. I, the undersigned, further certify that I am legally authorized as the patient, or as the patient’s parent or legal guardian, to execute the above and to accept its terms. PATIENT NAME OR NAME OF DATE PARENT/ LEGAL GUARDIAN (PRINTED) PATIENT SIGNATURE OR DATE PARENT/ LEGAL GUARDIAN SIGNATURE PATIENT PREFERRED NAME PATIENT DATE OF BIRTH