This information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
This authorization shall be in force and effect request otherwise. I understand that I have the right to revoke this authorization, in Writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or State law.
We inform all patients on our registration form and on this website of our request for a 24 hour cancellation from you, which will not incur a fee for cancellation. If you can't make your appointment, please let us know as soon as possible So we can offer it to Someone else. Your Consideration is appreciated because the sooner you call us the greater our chances of providing this time to Someone else. If a person fails to show for an appointment and does not provide 24 hour notice prior to cancelling there will be a $50.00 charge for the missed appointment. These charges will not be billed to your insurance provider. Your appointment time is allotted to you so we will charge you for failure to Call.
This policy applies to the following missed appointments: