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LATE CANCELLATION /
NO SHOW POLICY |
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Due to the
increased demand for appointment times, we have to implement a
Late Cancellation/No Show Policy. We regret that we have
had to take these steps. Our concern for seeing our patients in
a timely manner has prompted us to take these steps. We ask for
a 24 hour notice for all cancellations. |
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If patients
appointment has been confirmed and the patient fails to keep
said appointment, there will be a fee assessed to the amount
depending on the type of appointment scheduled; i.e., routine
follow up $25.00 or procedure $50.00. |
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I have read and
fully understand my responsibility as patient. |
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FILING OF INSURANCE CLAIMS |
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We will gladly file your claim
accurately and promptly once. In order to do this properly, we need
Current, Correct, and Complete insurance information.
Please verify information routinely. |
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The charges become due by the patient |
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We encourage you to call your insurance
company, and resolve the problem. We no longer can wait indefinitely
for payment. If the insurance company should pay us at a later date,
we will gladly refund any money paid by patient. |
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I have read the above and fully
understand my responsibility as a patient. |
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