Integrated Medical Weight Loss

1) 24-Hour Cancellation Policy

As a courtesy, we provide 2 automated reminders for each appointment (by phone, text or email) - 1-week prior and again 2-days prior to scheduled appointment.

If you are unable to keep your appointment, we do require notice within 24-hours of scheduled appointment. We have many patients waiting to be seen so your advance notice allows us to fill your spot.

A charge of up to $75 will be assessed for each No Show or Late Cancellation (less than 24 hrs).

We understand that emergencies & situations arise that are out of your control. These situations will be considered on a case by case basis. Thank you for your understanding & cooperation with this policy.

Signature of Patient (or responsible party): * Date: *

2) Financial Policy

To help you understand your financial responsibilities in relation to your medical care, we would like to briefly outline our financial policies.

We participate in most insurance plans, including Medicare. Knowing your insurance benefits is your responsibility. We suggest you contact your insurance company with any questions you may have regarding your coverage. If you are not insured by a plan we participate with, payment in full is expected at each visit. As a convenience, we offer discounted rates for self-pay patients.

All co-payments are due at the time of service. Deductibles and co-insurance will be billed after being processed by your insurance.

It is your responsibility to notify us of any changes in your insurance coverage so we can make the appropriate updates to help you receive your maximum benefits. If we do not have your correct/updated insurance information, you will be responsible for the full amount of visit.

I have read and understand this financial policy and agree to abide by it's guidelines:

Signature of Patient (or responsible party): * Date:

3) Acknowledgement of Privacy Practice (HIPAA)

By signing below, I am consenting to allow Integrated Medical Weight Loss to use and disclose my PHI to carry out treatment, payment and healthcare operations. A copy of the Notice of Privacy Practices is available in the patient portal or on our website (Get Started page) - IntegratedMedicalWeightLoss.com

Signature of Patient (or responsible party): * Date: *

4) Personal Health Information (PHI) Disclosure Designation

Would you like to authorize any other person to give/obtain your PHI: * If so, who: Relationship to patient: Signature of patient (or responsible party) Date: