Missed Appointment Policy. Your appointment time is reserved for you alone. We have a list of people waiting for earlier appointments. Please be courteous, and when at all possible, provide as much notice as you can. If you must cancel or reschedule an appointment, we ask that you provide notice of at least 24 hours. Should you have a late cancellation, no show or late arrival for your appointment, this will be considered a missed appointment. We define a missed appointment in the following ways: Same Day or Late Cancellation: Notice of less than 24 hours of your inability to attend a scheduled appointment. No Show: Failure to provide any notice of your inability to attend the appointment prior to the appointment time.
Missed Appointment Policy. Because I set aside a specified time for patients, I ask to be compensated for the full cost of a session if a scheduled appointment is missed or cancelled with less than 24-hours’ notice given. Hazardous road conditions severe enough to cause school closures would be a clear exception to this policy. This policy is also in place because a) regular sessions are necessary for psychotherapy to be effective and b) at least 24-hours’ notice of a cancellation gives me some time to notify others who may want your time slot which gives them the ability to rearrange their schedules. This is standard practice for psychologists. I Do Not Accept Insurance I do not accept insurance for payment for psychotherapy services, but you may be able to use health savings account funds and out-of-network benefits to help cover the cost. Ideally, psychotherapy takes place between a psychotherapist and a patient without the intrusion of any outside party such as an insurance company. This allows for the greatest flexibility and privacy and leaves the treatment decisions up to the patient and the therapist. • Confidentiality or privacy is compromised when filing claims with an insurance because a third party is involved in your treatment. Insurance companies often demand highly detailed information about your diagnosis, symptoms, level of functioning, and progress in treatment in order to determine whether or not they will reimburse the provider. • Insurance companies can and do dictate when and how treatment should take place, including when therapy should end, regardless of the opinions or expertise of the patient or psychotherapist. Instead, by not being an in-network provider with an insurance company, we are able to work together to determine the course of treatment which will be most helpful to you, rather than leaving that up to a representative from the insurance company. If you feel the use of insurance is a necessity for you, I would be considered an "out-of- network" provider. You would pay me directly and submit claims on your behalf for reimbursement (please check with your insurance company for your specific out-of-network coverage and their guidelines for submitting claims). I will provide you with documentation containing all the required information for you to submit your claim directly to your insurance company.
Missed Appointment Policy. If you cannot keep an appointment, we require a minimum of 24 hours notice. This courtesy on your part allows us to give the appointment to another patient needing to be seen. Please do not hesitate to ask if you have any questions regarding this financial agreement. We are committed to providing you with the ultimate experience in dental care. Print Name of Patient or Responsible Party Signature of Patient or Responsible Party Date I authorize my insurance company to pay my dental benefits directly to Xxxxx DMD and Xxxxx DDS:
Missed Appointment Policy. If a patient schedules an appointment and fails to show or cancel the appointment at least 24 hours in advance, they will be considered a “no show” for that visit. Patients will be charged a $75 per hour fee for every missed appointment. This fee is not covered by insurance and is the patients’ responsibility. We have created this policy in an effort to be able to see patients in need as quickly as possible. Returned Check Policy -‐ The return of a check (electronic or paper) issued to the Dental Center of Westport will incur a $45.00 “returned check” fee. Collection Policy – If we are forced to send a patient to collections for failure to make payment or if a patient declares bankruptcy, they will be expected to pay all charges in advance for any future appointments. Patient/Guardian Name (Print) Signature Date RELEASE AND STATEMENT TO PERMIT PAYMENT OF PRIVATE INSURANCE BENEFITS TO THE PROVIDER I, the responsible party listed below, hereby authorize this office, including its employees, to release and disclose all or any part of the patient’s medical records to any entity which is, or may be liable, for all or part of the provider charges. I, the responsible party listed below, hereby authorize the release and disclosure of any and all of my child’s medical records to any other entity, including, but not limited to specialty hospitals, physicians or other health care providers which may be of assistance in the opinion of this office, in providing treatment of the patient. I, the responsible party listed below, hereby authorize the release of any records necessary to assist in the reimbursement of insurance benefits to which I may be entitled. I, the responsible party listed below, hereby authorize the office and its employees to release medical records which are needed in ordered to provide the patient with the most appropriate medical care. I, the responsible party listed below, hereby authorize and request the payment of my third party or insurance company benefits be made directly to this office for any services or treatments given to the patient. The signature provided below shall suffice for all insurance forms on a continuing basis. Patient/Guardian Name (Print) Signature
Missed Appointment Policy. If a scheduled appointment is missed, cancelled with less than a 4-hour notice or you are more than 15 minutes late it is considered a “Missed” appointment.
Missed Appointment Policy. Due to the large block of time reserved for a massage therapy treatment and the limited number of patients we can treat each day, it is important for us to be able to fill this time when there is a cancellation. Therefore, a 24-hour cancellation notice is requested for this purpose. A fee of half the scheduled treatment cost will be charged (with discretion) to the account whenever insufficient time is given to rebook.
Missed Appointment Policy. I understand that I will attend each scheduled appointment. If I am unable to attend, I will call to cancel the appointment within 24 hours. I understand that I may be charged a tutoring session fee of $55.00 if I give less than 24 hours notice, and I will be responsible for this charge. I understand that future appointments may not be scheduled until this fee is paid. Agreement to Pay for Professional Services (initial) I have been informed of the costs of services and understand that I am responsible for the cost of services in their entirety. I understand that it is my responsibility to contact my insurance company to determine if my insurance company provides coverage for any of these services. I also understand that Foundations will provide me a statement of services, at my request, if I choose to submit information to my insurance company. (initial) Payment Arrangements I give Foundations Dyslexia and Learning Centers permission to charge my credit or debit card if my account has a balance over 90 days past due, including missed appointment fees. *This information will be kept in your confidential file Credit Card # Mastercard Visa Discover American Express Exp Date: 3-Digit Code Printed Name on Card: Signature: Date: I consent to treatment and agree to abide by the above stated policies and agreements with Foundations Dyslexia and Learning Center of Bloomington. Signature of Client/Legal Guardian Date
