I understand that by signing this form, I am obligated to check IN AND OUT with the Front Desk at each of my appointments to ensure all of my financial obligations and balances are satisfied. Failure to do so will result in being dismissed from the practice.
By signing below, I am declining to keep a credit card on file with Holistic Health Associates. As a result, I understand that I will be financially responsible for the full self-pay amounts of the scheduled service(s). I understand I must pay for my service prior to the service being rendered. I understand that if HHA will be processing my claim to my private insurance, I am responsible for the full patient responsibility balance determined by my insurance company and that I am responsible for the full self-pay amount of the scheduled service if my claim is denied.
I also understand that by choosing not to keep a credit card on file, this does not absolve me from the office’s policies, including the Cancellation Fee. By signing this document, I am financially responsible for the Cancellation Fee, in full, should I not adhere to the details of the Cancellation Policy.
An appointment reserves time in our office. To ensure that the maximum number of patients can receive care when needed, we require notification of any appointment changes 24 hours in advance of your appointment. A $75 fee will be assessed for any missed appointments or cancellations with less than 24-hour notice. Electronic Appointment Reminders via text and email are sent as a courtesy and inability to receive one is not an excuse to miss an appointment. Ultimately, it is the responsibility of the patient to keep track of their appointments. Disputing cancellation fees or non-adherence to office policies could result in scheduling privileges being revoked.
