Patient Agreement

*To be signed by all new patients prior to their first appointment

New Patient Appointments

• I agree to arrive 45 min prior to my new patient appointment time. This time is reserved to fill out paperwork, assessments and insurance verification. Arriving late may cause the office to reschedule my appointment and incur a $300 fee.
• If I need to cancel or reschedule my new patient appointment I will call 24 hours in advance, otherwise I will incur a $300 fee which is not covered by insurance.
• Should I no-show to my new patient appointment the office reserves the right to not reschedule my appointment.

Please note that Saturday and Sunday are not valid cancellation days. If you have a Monday appointment or an appointment after a holiday, you will need to contact us the business day prior to your scheduled appointment.

Follow-Up Appointments

• I agree to arrive on time to my follow up appointments. Arriving late may cause the office to reschedule my appointment and incur a $75 fee.
• If I need to cancel or reschedule my follow up appointments I will call 24 hours in advance, otherwise I will incur a $75 fee which is not covered by insurance.

Please note that Saturday and Sunday are not valid cancellation days. If you have a Monday appointment or an appointment after a holiday, you will need to contact us the business day prior to your scheduled appointment.

Medication Management

• Refills may not be given if I have not been seen in the last 3-6 months.
• I will request refills through my pharmacy at least 2 days prior to running out of medication. A nominal fee may be charged for same-day/after-hours requests.
• I will request refills for controlled substances from my provider 3-5 days prior of running out of medication. I will send a request through the portal or leave a message on my provider’s voicemail. A nominal fee may be charged for same-day/after-hours requests.
• I will notify my provider immediately if I am prescribed a controlled substance by another provider.

Insurance

• It is my responsibility to inform the office of any insurance changes.
• I agree to pay my copay or deductible at the time of service.

Acknowledgement

By completing and submitting the form below, I acknowledge I have read and understood the above patient agreement.





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