MISSED OR LATE APPOINTMENT POLICY Signature: Description of Representative's Authority and Patient Name: -OR- Print Name: Date Signed: Date Signed: Print Name: Signature: Patient Representative Date of Birth: I have read and understand the Missed or Late Appointment Policy above. Kidney Care Physicians asks that you read and sign this Missed or Late Appointment Policy prior to treatment in our office. Our policy is to call patients one day prior to the appointment to remind them of the date and time. These calls are a courtesy to our patients and it allows us the opportunity to schedule another patient in that appointment time if you choose to cancel. Missed appointments or arriving late for an appointment prevents other individuals from seeing their provider in a timely manner. Please note that a pattern of missed appointments, last minute cancellations, or being late for the scheduled appointment will result in possible discharge from Kidney Care Physicians. As a courtesy to other patients Kidney Care Physicians asks that you arrive 20 minutes prior to your scheduled appointment time. If you are 15 minutes past your scheduled appointment your provider may not be able to see you and you will be asked to reschedule the appointment. If you are unable to keep your scheduled appointment, call us 24 hours prior to your scheduled appointment. If we do not receive a call and you miss your appointment there may be a $50.00 fee assessed to your account for that missed appointment. You will be responsible for this payment as your insurance will not pay this fee and it will be due prior to scheduling another appointment. Please call and ask for the Billing Office to settle this payment and schedule a new appointment at your convenience. Kidney Care Physicians gives you the right to appeal any or all charges or fees assessed to your account. If you have any questions or would like to appeal a fee assessed for a missed appointment please call (503) 561-8565 and ask for the office manager.

MISSED OR LATE APPOINTMENT POLICY - … have read and understand the Missed or Late Appointment Policy above. Kidney Care Physicians asks that you read and sign this Missed or Late

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MISSED OR LATE APPOINTMENT POLICY

Signature:

Description of Representative's Authority and Patient Name:

-OR-

Print Name:

Date Signed:

Print Name:

Signature:

Patient Representative

Date of Birth:

I have read and understand the Missed or Late Appointment Policy above.

Kidney Care Physicians asks that you read and sign this Missed or Late Appointment Policy prior to treatment in our office. Our policy is to call patients one day prior to the appointment to remind them of the date and time. These calls are a courtesy to our patients and it allows us the opportunity to schedule another patient in that appointment time if you choose to cancel. Missed appointments or arriving late for an appointment prevents other individuals from seeing their provider in a timely manner. Please note that a pattern of missed appointments, last minute cancellations, or being late for the scheduled appointment will result in possible discharge from Kidney Care Physicians. As a courtesy to other patients Kidney Care Physicians asks that you arrive 20 minutes prior to your scheduled appointment time. If you are 15 minutes past your scheduled appointment your provider may not be able to see you and you will be asked to reschedule the appointment. If you are unable to keep your scheduled appointment, call us 24 hours prior to your scheduled appointment. If we do not receive a call and you miss your appointment there may be a $50.00 fee assessed to your account for that missed appointment. You will be responsible for this payment as your insurance will not pay this fee and it will be due prior to scheduling another appointment. Please call and ask for the Billing Office to settle this payment and schedule a new appointment at your convenience. Kidney Care Physicians gives you the right to appeal any or all charges or fees assessed to your account. If you have any questions or would like to appeal a fee assessed for a missed appointment please call (503) 561-8565 and ask for the office manager.