Policy for Missed Appointments and Cancellations Clause Samples

Policy for Missed Appointments and Cancellations. Appointment times are reserved exclusively for you. The office must be notified at least 24 hours in advance to cancel or change your appointment. Missed appointments or late cancellations will be charged the FULL FEE for the scheduled service. If you have had a fever, cough, or symptoms of any illness within 10 days of or on the day of your office visit, please contact the office to reschedule free of charge. For questions, please contact ▇▇▇-▇▇▇-▇▇▇▇ Office or ▇▇▇-▇▇▇-▇▇▇▇ ▇ ▇▇▇ Billing. BY SIGNING THIS FINANCIAL AGREEMENT, I HAVE READ ALL ITEMS AND ACCEPT THE TERMS: _ _ Patient or (Authorized Parent/Guardian Name) Printed Patient or Authorized Parent/Guardian Signature Date Our office will always hold your appointment times for you in the schedule, and in return requests that you fill out this form. This form authorizes our office to bill your credit card for services and missed sessions. It is kept confidential and private. As a reminder, your insurance company will not reimburse you for missed sessions or late cancellations. Appointments must be canceled within 24 business hours to avoid a fee. Typical Fee for Services: $350 Initial Evaluation $100-$175 Routine Follow Up $250 Extended Follow-Up Reports/Other Services - Varies I, the undersigned individual, authorize Well Being Systems, PLLC, to charge my credit card for all account balances, including: • Missed appointments or late cancellations, billed at the full rate of the scheduled appointment • Outstanding payments for services rendered, including co-pays, deductibles, and co-insurances • Fee for Self-Pay services, as determined by the provider • Claims that have been denied or unpaid by your insurance after 90 days • Any professional services not billable to insurance • Reports and other account balances not stated above Your card will automatically be charged without notification for routine patient responsible amounts. The office will attempt to notify you prior to charging your card if we feel the charges are higher than anticipated. If we do not hear from you or are otherwise unsuccessful at reaching you, your card may be charged for the full or partial amount at the discretion of the office. You agree to not dispute charges for any of these reasons. You further authorize our office to disclose information about my attendance and/or cancellation to your credit card company if you dispute a charge. If you would like to use an HSA card, please provide a secondary source of payment in the case...