Jump to Content
 

Available Forms

2) New Patients: Cancellation & No Show Agreement

Cancellation & No Show Agreement

A ?no show? is someone who misses an appointment without canceling it by one (1) working day in advance.

We require that you call/email one (1) working day in advance.Reminder calls will be completed as a courtesy two (2) working days by text message and one (1) working day by phone between 7 am-7pm. Canceling thru the automated reminder is not subject to a ?no show?, as these are delivered in the allotted time for cancellation.

Rescheduling your appointment to another day and is less then 24 hours in advanced, this is considered a late cancellation. Late cancellations will be considered as a ?no show?.

To cancel appointments please: call 206-453-4215, email appt@hometownedoc.com, or choose the cancellation option via automated reminders.

 

Same day cancellations and reschedules are subject to a $50.00 administrative fee.

An administrative fee of $150.00 will be billed to the patient?s account and attached to your monthly statement after the third (3) no-show. - Medicare /Medicaid Apple health patients will be temporarily suspended from services for 6 months after third (3) no show.

The fourth (4) no show and any after are subject to a fee of $200.00.

Six (6) ?no shows? will result in the temporary suspension of services.

Each occurrence will erase after a 12 month period.

 

I acknowledge that I have access to an electronic copy of the cancellation policy via UPDOX forms. I have read the policy and understand it and the highlighted terms above. I agree to any fees that occur if I do not adhere to the cancellation policy. If I fail to make the payments related to a ?no show? fee, I understand that the account can be turned over to a collections agency and possible dismissal from HOME TOWNE FAMILY MEDICINE.

* Required field