Center for Holistic Medicine
9 Brookwood Avenue Carlisle, PA 17015
(717)243-0616 FAX: (717)245-2351
Purpose: This form is used to document (a) an individual’s acknowledgement of receipt of our Privacy Practices Notice or (b) when we have not obtained this acknowledgement, our good faith effort to obtain the acknowledgement.
acknowledge that I have received a Privacy Practices Notice from the Center Holistic Medicine.
I attest that the above information is correct.
Effective October 2015
We require a credit card number to be put on file to schedule appointments. To be considered an active patient an onsite visit must be made at least 1 time per year. All follow ups must be done in person or by telephone (as recommended by your physician)
All services are provided by appointment only and this scheduled time is for your exclusive use. Cancellation policy differs by type of appointment as written below.
All new patients are required to give a 1 week cancellation notice due to the length of the appointment and time spent by the physician reviewing your records. Center for Holistic Medicine retains the deposit of $200.00 as nonrefundable. If you do not call or just do not show up for your appointment you will be billed for the remaining amount of $200.00. These appointments are very involved and time consuming)
Note: Appointments can be rescheduled at the physician’s discretion.
All new patient appointments are required to give a 1 week cancellation notice prior to your scheduled appointment. Center for Holistic Medicine retains the $87.50 deposit as nonrefundable if cancellation policy is broken.
Note: Appointments can be rescheduled at the physician’s discretion.
We require 48 hour notice for follow up cancellations for Functional Medicine/Autism Spectrum management which include office visits and telephone consults with the doctor. Center for Holistic Medicine retains the right to bill $100.00 of the standard fee for any consultation not cancelled within 48 hours prior to the visit.
We require a 48 hour notice for cancellation of follow up acupuncture visits. Center for Holistic Medicine retains the right to bill $50.00 of the standard fee for any consultation not cancelled within 48 hours of the scheduled visit.
Note: Fees for non-cancellation of follow up appointments are nonrefundable and may not be used as credit to a future consultation or procedure.
As a part of our effort to provide you with the very best medical care, our clinicians use emails as a form of communications with patients.
Please note that if you choose to submit our invoices to your insurance company for reimbursement, telephone consults are not generally covered by insurance and email correspondence is not covered by insurance. You should not submit invoices for email correspondence to your insurance provider.
If you have any questions regarding any of these policies, please call us at 717-243-0616.
Thankyou.
If the patient is a child both parents/guardians must sign below.
have read and understand the above outlined policies regarding
email. I also understand that email is NOT 100% secure.
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