Payment, Cancellation and Late Arrival Policy

Please correct the errors described below.

Payment Policy

All Co-payments and any past due balances are due at the time of visit. If you receive a bill and would like to make payments, this will need to be arranged with our office staff. Please contact the office at (773) 244-9600.

No Show/Cancellation Policy

As our practice continues to grow, we have updated our cancellation policy to better serve our patients. Your appointment time is reserved especially for you. Please call (773) 244-9600 at least 24 hours before your scheduled appointment if you need to cancel or reschedule. This will allow our staff to offer that appointment slot to another patient who needs medical care.

If you do not cancel your appointment at least 24 hours in advance, you will be charged a no show or late cancellation fee of $100 (for Telemedicine). This fee is not covered by insurance.Please note, if you booked an IN-OFFICE appointment and do not cancel your appointment at least 24 hours in advance, you will be charged an IN-OFFICE no show fee of $200.You will not be able to reschedule the missed appointment until the fee has been paid in full.

We understand that life gets busy. However, a pattern of missed appointments without proper notice does not show mutual consideration. Patients who fail to provide advanced cancellation for three appointments in the span of one year may be subject to dismissal from the practice.

Late Arrival Policy

We know that delays can happen when you are trying to get to your appointment. However, we must try to keep the other patients and our providers on time. If you arrive 15 minutes past your scheduled appointment time, we may have to reschedule your appointment. If you know in advance that you are going to be late, please let us know if possible and we will do our best to accommodate you.

I have read and acknowledge your Payment, Cancellation and Late policies.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Loading...