Notification of Missed Appointments and Fees


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.

I understand I will be financially responsible for any services received.

APPOINTMENTS

All new patients are seen for a 50 minute session.

Follow-up appointments are 20 minutes.

FEES

Initial Evaluation $399.00

Follow-up Evaluation $175.00

First Missed Appointment -0-

Follow-up Missed Appointment or NCNS (no call no show) $150.00

FOLLOW UP APPOINTMENTS

Due to limited appointment availability, 24 hours notice is required to cancel any appointments for an established patient. Canceling appointments may be done over the phone or by sending fax to our office. Our office will refer to the time of the call or time of the fax to judge whether you will be charged or not. If this policy is not followed you will be charged for the missed appointment.

These rates are non-negotiable and will be charged to the patient’s credit card on the date of the missed appointment. All patients are required to provide a credit card number that the office will use and keep in the patient’s medical chart and we only use for missed appointments and balances due on the account that are over 30 days past due. If you do not have a credit card, please call the office and ask to speak to the business manager about this to make other arrangements.

PAYMENT OF SERVICE

Psychiatric Nurse Practitioner Nikki Katibi’s psychiatric diagnostic and medication services are due at time of service.

ACKNOWLEDGEMENT

By signing this form, you acknowledge you have read and understand the office policies of Psychiatric Nurse Practitioner Nikki Katibi.

You are aware that if an appointment is missed and you have not given the required 24 hour notice of cancellation, then the office will charge your credit card (Visa/Mastercard/American Express/Discover). Missed appointment fees are your responsibility.

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.

Leave this empty:

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Document name: Notification of Missed Appointments and Fees
Unique Document ID: e888c29aca75271e7de49f71e147c6d5d898b1b3
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August 2, 2018 5:27 pm CSTNotification of Missed Appointments and Fees Uploaded by imo imo - imo@inmindout.com IP 23.122.45.227