Cancellation and Missed Appointment Policy. Scheduled appointment times are reserved especially for you. If an appointment is missed or canceled with less than 24 hours notice, you will be billed according to the scheduled fee and instructions of the benefit plan. Repeated "no-show" appointments could result in referring you back to the insurance or managed care company for reassignment to another practitioner. Your insurance company will not be billed for fees associated with missed or canceled appointments. Initial here: YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. / / Patient or Guardian Signature Date Consent for Treatment I (the patient or guardian) authorize and request my practitioner to carry out psychiatric exams, prescribe medication, and provide psychiatric treatment and/or diagnostic procedures, which now, or during the course of my treatment, become advisable. I understand the purpose of these procedures will be explained to me upon my request and that they are subject to my agreement. I also understand that while the course of my treatment is designed to be helpful, my practitioner can make no guarantees about the outcome of my treatment. Further, the psychotherapeutic process can bring up uncomfortable feelings and reactions such as anxiety, sadness, and anger. I understand that this may be a normal response to working through unresolved life experiences and that these reactions will be worked on between my practitioner and me. It is also possible that psychiatric medication prescribed may have uncomfortable side effects. Patient/Guardian Signature Date Practitioner Signature Date
Cancellation and Missed Appointment Policy. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. If you fail to provide a 24-hour notice, you will be charged $70.00 (Fee does not apply to Medicaid; however, you are still required to give a 24-hour notice). I cannot bill your insurance company for a missed appointment. If you give me a 24-hour notice of your intention not to meet for one of your appointments, you will not be charged. If my office is closed or you are unable to reach me, you may leave a voicemail canceling your appointment. If you do not show for an appointment either in-person or via Telepsychology/Teletherapy, you will be charged $70.00. After a missed appointment (i.e., Failure to provide a 24-hour notice or No Show for an appointment), if you do not contact me within 10 days to reschedule, I will accept that as your notice that you have terminated therapy with me.
Cancellation and Missed Appointment Policy. Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or cancelling an appointment. The full fee will be charged to you for sessions missed without such notification. Initial here
Cancellation and Missed Appointment Policy. If you need to cancel an appointment, please contact me with 24-hours notice. You will be charged for the missed or late- cancelled session unless there has been an emergency that we agree was beyond your control. The fee for a missed or late-cancelled appointment is $75.
