Notification of Missed Appointments and Insurance Coverage

Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours
advance notice of cancellation. Please understand that when you forget or cancel your
appointment without giving enough notice, we miss the opportunity to fill that appointment time, and
clients on our waiting list miss the opportunity to receive services. Since the services are reserved for
you personally, a Cancellation fee will apply. We now require that you provide a credit card to have on
file to be charged for missed appointments or the cost of assessment, testing, therapy and/or Biofeedback/Neurofeedback training sessions that are not covered by insurance.

I understand I will be financially responsible for any services received at InMindOut that are not covered through my insurance.

By signing below I indicate I have read the information in this document and agree to abide by its terms. 

If client is a minor, please have the parent or legal guardian sign this form.

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InMindOut Emotional Wellness Center
Signature Certificate
Document name: Notification of Missed Appointments and Insurance Coverage
Unique Document ID: 790a4d5b0915a43f550ad263e35ae91b1f23866b
Timestamp Audit
October 17, 2017 9:16 am CDTNotification of Missed Appointments and Insurance Coverage Uploaded by Amanda Bergeron Bergeron - IP
January 15, 2018 11:38 am CDT Document owner has handed over this document to 2018-01-15 11:38:27 -