Healthcare Patient Attendance Agreement

HEALTHCARE PATIENT ATTENDANCE AGREEMENT

This Healthcare Patient Attendance Agreement (the "Agreement") sets forth the obligations of the patient and the practice regarding scheduling, attendance, cancellations, and related financial responsibilities for appointments and telehealth encounters. Patient Name: Date of Birth:

PATIENT INFORMATION

EMERGENCY CONTACT

INSURANCE INFORMATION

MEDICAL HISTORY (RELEVANT TO CARE)

ATTENDANCE, CANCELLATION & NO-SHOW POLICY

Patient agrees to attend all scheduled appointments on time and to provide adequate advance notice for cancellation or rescheduling. The practice requires at least hours' notice for cancellations. Failure to provide timely notice may result in a fee. No-show fee: $ . Fees for missed appointments or late cancellations are charged when the missed appointment directly prevents care delivery to other patients or incurs unrecoverable costs.

The practice will attempt to notify the patient of scheduled appointments by the preferred contact method on file. It remains the patient's responsibility to confirm appointments. Repeated late cancellations or no-shows may result in discharge from the practice following documented attempts to address the issue.

LATE ARRIVAL

If the patient arrives late, the provider may determine whether the appointment can be completed within the remaining time. If not, the appointment may be rescheduled and may be treated as a late cancellation subject to applicable fees.

TELEHEALTH ATTENDANCE

For telehealth appointments, patient must be in a private location with sufficient connectivity and must join at the scheduled time. Technical difficulties that prevent a successful encounter may be treated as a missed appointment if rescheduling is required. By checking the box below, the patient consents to receive care via telehealth and accepts the attendance requirements for telehealth encounters.

BILLING & FINANCIAL RESPONSIBILITY

The patient (or guarantor) is responsible for all charges not covered by insurance, including copayments, deductibles, and fees for missed appointments. The patient authorizes the practice to bill the listed insurance and understands that outstanding balances may be transferred to collection if not resolved. If the patient is uninsured or chooses not to use insurance, charges remain the patient's responsibility.

HIPAA PRIVACY & ACKNOWLEDGMENT

The patient acknowledges receipt of the practice's Notice of Privacy Practices and understands how health information may be used and disclosed for treatment, payment, and healthcare operations. The patient may request restrictions on disclosures and may revoke authorizations in writing, subject to limitations described in the Notice of Privacy Practices.

AUTHORIZATION & TERM

By signing below, the patient certifies that the information provided is accurate to the best of their knowledge, agrees to comply with the attendance and cancellation policies stated herein, authorizes release of medical information to insurers as necessary for claims processing, and accepts financial responsibility as described. This authorization shall remain in effect until:

The patient may withdraw consent or request amendment of information consistent with applicable law. Withdrawal of consent does not affect actions taken by the practice prior to receipt of such withdrawal.

ADDITIONAL NOTES

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