HTFM Patient Portal - Publicforms

Available Forms

*1 New Patients: Consent for Treatment & Payment & Acknowledgements *2 New Patients: Cancellation & No Show Agreement *3 New Patients: Text Messaging *4 New Patients: Patient Financial Responsibility *5 New Patients: Updox Patient Portal *6 New Patients: Telehealth (VideoChat)Consent form *7 New Patients: Alternate Phone/Person *8 New Patients: Address and Insurance form *9 New Patients: Medical Records Request To Us 10) New Patients: Please Read! Thank you! 24) Patients Rights & Responsibilities 27) Telehealth (VideoChat) Consent form 31) Address and Insurance Update form 34) Consent for Payment Plan 35) Medical Records Request From Care Management Request for Medicare CCM Staff Log Patient Satisfaction Survey Prescription Refill Request

*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 $125.00 administrative fee. The administrative fee of $125.00 fee will be automatically charged to the card on file for same day no shows, cancellations or reschedules.(Subject to Assistant Manager Discretion)

An administrative fee of $200.00 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 $250.00.

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. By signing this form I also allow Home Towne Family Medicine to charge my card on file for fees accrued as described in the policy.

Patient Name *

Date of Birth *

Date *

Please be advised this policy and fee are subject to review and the terms of this agreement and associated fees maybe increased by our clinical director. Patients will be notified via email 30 days prior to any fee changes.

* Required field