MISSED OR CANCELLED APPOINTMENTS. When you make an appointment, we reserve that time for you. When a patient misses or cancels their appointment, it takes away precious time the mental health provider could be spending treating another patient. PLEASE BE ADVISED THAT SYNERGISM COUNSELING WILL CHARGE A $75.00 LATE CANCELLATION FEE IF 24 HRS ADVANCED NOTICE IS NOT GIVEN AND UP TO THE FULL SERVICE AMOUNT IF YOU MISS YOUR APPOINTMENT WITH NOT ADVANCED NOTICE.
MISSED OR CANCELLED APPOINTMENTS. Office and/or telemedicine visits are by appointment only. All administrative and billing matters, including copayment and completion of any forms, are expected to be completed before the time of your appointment. Patients are asked to arrive 15 minutes before the scheduled appointment time in order to complete the check-in process. Patients arriving more than 20 minutes late may be required to reschedule their appointment for the next available opening consistent with the type of appointment requested. Please look carefully over pages 4-11 of this document, then initial each statement. I, the undersigned, agree that I: have reviewed and agree with the Notice of Privacy Practices & Patient Rights (pages 4-5) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 6-7) have reviewed and agree with the Consent to Bill and Release Medical Information to Insurance Company (page 8) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 9-10) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 11) I, the undersigned, herby certify that I have provided correct information about the patient during registration. I understand that any false statements or concealment of material fact may be prosecuted under applicable federal and state laws. I certify that I have read, fully understand, and accept the above information, terms, and conditions. I, the undersigned, further certify that I am legally authorized as the patient, or as the patient’s parent or legal guardian, to execute the above and to accept its terms. PATIENT NAME OR NAME OF DATE PARENT/ LEGAL GUARDIAN (PRINTED) PATIENT SIGNATURE OR DATE PARENT/ LEGAL GUARDIAN SIGNATURE PATIENT PREFERRED NAME PATIENT DATE OF BIRTH
MISSED OR CANCELLED APPOINTMENTS. Office and/or telemedicine visits are by appointment only. All administrative and billing matters, including copayment and completion of any forms, are expected to be completed before the time of your appointment. Patients are asked to arrive 15 minutes before the scheduled appointment time in order to complete the check-in process. Patients arriving more than 20 minutes late may be required to reschedule their appointment for the next available opening consistent with the type of appointment requested.
MISSED OR CANCELLED APPOINTMENTS. If you need to cancel an appointment, or you are going to be late, please ring or text. If you don’t turn up for your booked session and don’t let us know within 24 hours you will be charged the full cost of your session. Personal conduct Therapy cannot take place if the client arrives at the session under the influence of alcohol or illegal drugs, nor will sessions continue if a client becomes threatening or violent towards the therapist.
MISSED OR CANCELLED APPOINTMENTS. In order to accommodate other patients who may be waiting for treatment, we require 24 hours notice if you must cancel. We reserve the right to charge a $35.00 fee for any appointments not kept or cancelled within 24 hours. ● HIPAA PRIVACY PRACTICE NOTICE I acknowledge that there is a copy of the Notice of privacy Practice displayed in the office and on SMART Sports website xxx.xxxxxxxxxxxxxx.xxx that I will be given a copy of if requested. I have read and understand the above.
MISSED OR CANCELLED APPOINTMENTS. If you are unable to keep your appointment for any reason, please call me and cancel. My voice mail is available seven days a week, 24 hours a day to take your message. If an appointment is cancelled with less than 48-hour notice, I reserve the right to incur a late cancellation fee of $30. Appointments that are missed without any notice may incur a no-show fee of $60. Please be aware that your insurance provider will not pay for either missed or cancelled sessions and you are responsible for 100% of that charge. If you are late for your appointment and have not called me, I will keep your time free until 15 minutes after the scheduled start time.
MISSED OR CANCELLED APPOINTMENTS. Sessions are typically scheduled to occur one time per week at the same day and time if possible. I might suggest a different frequency depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome. Your appointment is specifically reserved for you. If you have to cancel, please let me know as soon as you can. Unless a 24-hour notice is given, missed or cancelled appointments will be charged for the usual session fee. Clients whose services are being reimbursed by insurance will be expected to pay the full fee for appointments missed without 24-hours advance notice. The insurance company will not cover an appointment for which you are not present, so the full fee will be your co-pay plus the amount the insurance would have paid if you were present.
MISSED OR CANCELLED APPOINTMENTS. Missed or cancelled appointments will incur your usual fee for the time scheduled unless a 24-hour notice is given. You may always leave a cancellation notification or a request for a change in your appointment time on my answering machine or in an email, weekdays or weekends. Telephone calls and emergency services I will do my best to return all calls within 24 hours. My phone number 000-000-0000, is both my personal and professional mobile phone, and is only used by me. It is confidential. Because of the nature of private practice, I do not offer 24-hour crisis services, however I will make every attempt to be available to you as quickly as I am able during the daytime work week. If you are unable to reach me, and you need immediate assistance, please call the Sutter Center for Psychiatry at 000-000-0000, or the Yolo County Crisis Line at 530-756- 5000, or in case of a life-threatening situation please call 911. If you have further questions about after hour situations please feel free to ask me for more information.
