*Please upload a photo of your insurance card and ID once granted access to the portal. This occurs when you are removed from the waitlist and provided a new patient appointment.
Information of Policy Holder or Financially Responsible Party (If Not Self)
Office Policy Agreement
All sessions of the course must be attended in order to obtain the certificate of completion.
Should you become a patient of the practice in the future be advised of the following policies.
All cancellations/reschedules made at least 24 hours in advance of the scheduled appointment are not charged. If you late cancel or no show your new patient appointment, you will not be given another appointment option with this office. After your new patient appointment, late cancellations/reschedules and no-show appointments will be charged according to the current fee. Insurance will not reimburse you for this charge. For repeated no-shows or late cancel/reschedules, all future appointments will be canceled until you are able to attend scheduled appointments without missing them.
This practice requires a credit/debit card on file to secure appointments. You will be asked to submit this number through the patient portal, which is a secure file. This card will be used primarily for copayment/co-insurance/session fees and for no-shows and late cancellations. By agreeing to the terms and providing your credit/debit card, you are acknowledging that you are aware that your card will be charged according to the office policies. After agreeing to the terms and providing your credit/debit card, if you contact your bank or card company to deny this charge, resulting in a “chargeback,” any additional fees associated with that chargeback will be added to the original missed appointment fee. Thank you for your cooperation with this necessary policy.