Common use of MISSED OR CANCELLED APPOINTMENTS Clause in Contracts

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 3-10 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 3-4) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 5-6) have reviewed and agree with the Consent to Xxxx and Release Medical Information to Insurance Company (page 7) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 8-9) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 10) PATIENT NAME OR NAME OF DATE PATIENT SIGNATURE OR DATE This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

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 10 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 3-10 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 3-4) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 5-6) have reviewed and agree with the Consent to Xxxx Bill and Release Medical Information to Insurance Company (page 7) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 8-9) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 10) have reviewed and agree with the Forms Request Procedure (page 11) have reviewed and agree with the Emergency Resources (page 12) PATIENT NAME OR NAME OF DATE PATIENT SIGNATURE OR DATE This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.

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 34-10 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 34-45) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 56-67) have reviewed and agree with the Consent to Xxxx and Release Medical Information to Insurance Company (page 7) 8) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 89-910) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 1011) PATIENT NAME OR NAME OF DATE PATIENT SIGNATURE OR DATE This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.DATE

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 34-10 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 34-45) have reviewed and agree with the Detailed Explanation of Consent for Psychiatric Evaluation and Treatment (pages 56-67) have reviewed and agree with the Consent to Xxxx Bill and Release Medical Information to Insurance Company (page 7) 8) have reviewed and agree with the Telemedicine & Online Counseling Agreement (pages 89-910) have reviewed and agree with the Consent for Telephone, Email and SMS Text Messaging (page 1011) PATIENT NAME OR NAME OF DATE PATIENT SIGNATURE OR DATE This notice describes how medical information about you may be used and disclosed, and how you can get access to this information.DATE