Appointment Cancellation Policy. Charges apply for appointments canceled (or changed) with less than 24 hours notice. Extenuating circumstances are considered when appropriate. Insurance benefits do not cover cancellation charges. (Client’s Initials)
Appointment Cancellation Policy. In an effort to keep our patients and staff as safe as possible, we encourage you to re-schedule your appointment if you have any signs or symptoms of illness. We ask that you provide us at least 24 hours’ notice for appointment cancellation or rescheduling of appointments. If you should have any combination of three appointment cancellations with inadequate notice and/or “no shows” for scheduled appointments, we reserve the right to cancel any remaining appointments, notify your physician and discharge you as a patient. You may reach us by voicemail at your convenience during non-working hours, weekends and holidays.
Appointment Cancellation Policy. If you must reschedule your behind-the-wheel session, notify your behind-the-wheel teacher at least 24 hours prior to your scheduled drive time.
Appointment Cancellation Policy. Service Provider requires 48 hours notice to cancel scheduled appointments. When possible, Service Provider will attempt to accommodate a moved appointment with less notice. However, if appointment cannot be moved to a different slot in the same week, this will count as a cancelled appointment if the requested notice was not provided. No shows and last-minute cancellations will be billed at the full hourly rate for the allotted time that was scheduled with a one-hour minimum.
Appointment Cancellation Policy. At Garden City Dental Care, we value your time and do our best to accommodate your schedule. If you cannot make an appointment as scheduled, please notify the office as soon as possible. There will be a charge of $50.00 per 60 minutes of scheduled time broken for a missed appointment, or cancellation with less than 24 hours’ notice. SIGNATURE: DATE:
Appointment Cancellation Policy. We require a cancellation notice, by phone or email, 24 hours prior to your scheduled appointment. The fee incurred for cancellations and no-show appointments without appropriate notice is as follows: $35 for Routine appointments and $50 for Annual Physical Exams. Participation Fee Selection Age (Years) Yearly Payment Quarterly Payment 17 – 29 $1,656 $414 30 – 49 $1,987 $497 50 – 64 $2,318 $580 65 – 79 $2,822 $703 80-89 $3,312 $828 90 & Up $3,816 $952 *IMPORTANT:: PLEASE SELECT AN OPTION BELOW BASED ON YOUR AGE AND DESIRED PAYMENT PLAN: Age Group 00-00 00-00 00-00 00-00 80-89 90 and Up Xxxx My Credit Card Annually Xxxx My Credit Card Quarterly Credit Card Payment Authorization (if paying by credit card) Name as it appears on credit card: Credit card billing address: Credit card type: Last 4 digits of credit card: Credit card expiration date: Security code on back of card: I have read and agree to the recurring billing plan terms of use described in Exhibit B. I hereby authorize Buckhead Concierge Internal Medicine, LLC doing business as Buckhead Medicine, to charge this credit card on a recurring basis for the Participation Fee indicated on Exhibit D. Authorized Card Holder Signature Today’s Date I understand and agree to all of the terms of the Concierge Medical Agreement described herein. I have reviewed the Annual Participation Fee table above and understand the Participation Fee adjusts based on my age group at time of renewal. The undersigned has executed this Agreement as of the day and year set forth below: Patient’s Full Name (printed) Patient or Patient’s Legal Representative Signature Today’s Date Authorization for Use/Disclosure of Protected Health Information I hereby request and authorize: records to: Hospital/Doctor to provide copies of my Xx. Xxxxxx X Espinosa, Buckhead Medicine, 00 Xxxx Xxxxxx Xxxx, Xxxxxxxx X, Xxxxx 0000, Xxxxxxx, Xxxxxxx 00000. Phone: 000-000-0000 Fax: 000-000-0000 This authorization applies to records or PHI Access from the following dates of service: _ _ The information used/disclosed pursuant to this authorization will not include psychotherapy notes (meaning detailed notes kept by your psychiatrist or psychotherapist) but may include other detailed mental health information, HIV/AIDS information and/or information regarding alcohol or substance abuse. Entire Medical Record Consult Reports
Appointment Cancellation Policy. Any changes or cancellations of a booked appointment must be requested a minimum of 48 business-day hours prior to the appointment by either email or phone. The Vendor, at its sole discretion, will charge an administrative fee of $250 plus HST, per appointment, to be paid by the Purchaser to the Vendor, as an adjustment in favour of the Vendor on Closing, for any appointment that has not been changed or cancelled with a minimum 48 business-day hour notice.
Appointment Cancellation Policy. We realize that there will be occasions when cancellation and rescheduling of your assigned drive time would be necessary, due to illness or emergency. If you are unable to attend the driving session, notification to your behind- the-wheel instructor 24 hours prior to your scheduled drive time is required. If you cannot reach the behind- the-wheel instructor, please contact the RCC driver training office at 956-7116.
Appointment Cancellation Policy. Please provide 24 hours advance notice if you are unable to attend a scheduled appointment. If you fail to do so, you will be charged the full fee amount for the missed session and expected to pay before the next session. To cancel an appointment, please call 00-0000-0000 and leave a message. Client’s Initial:
Appointment Cancellation Policy. You have been provided with my cancellation policy on the financial pol- icy form, please read it carefully.
