Missed Appointment / Cancellation Policy

Missed Appointment / Cancellation Policy

Cancellation policy is that it requires 24 hours notice otherwise they will be a charge

As of January 1, 2016, all patients who fail to arrive for their scheduled appointments or do not cancel with a 24-hour notice will be charged a missed appointment/cancellation fee of $50. This fee applies to all patients, regardless of their insurance status or insurer. Reminder texts/phone calls/emails are a courtesy, and a lack of receipt of a reminder is not a valid excuse for missed appointments.

Missed ppointment/cancellation fees are NOT covered by insurance, and will be the patient’s personal responsibility to pay. (Pursuant to CMS CR5613)

    Patient Name (Print)

    Date of birth

    Patient/Guarantor Signature

    Date