Acknowledgement of Receipt of Notice or Privacy Practices

1. I have read and received a copy of South Palm Family Center’s Notice of Office and Privacy Practices.
2. I hereby authorize South Palm Family Center to obtain medical information that may be needed for my healthcare.
3. I authorize one or both of the following persons to make/cancel/or receive any information regarding my appointments.
4. Referrals to specialists may require up to 1 (one) weeks’ notice to be fulfilled. In case of an emergency the office will try to expedite this service.
5. Medication refills require a 48-72-hour notice. Antibiotics will not be called into a pharmacy without an appointment. Other medications that need refills will not be called into a pharmacy after business hours.
6. NO SHOW POLICY – There will be a $25.00 fee for missed appointments or cancellations with less than 24-hour notice. Patients that have a history of repeated ‘NO SHOWS’ may be subject to dismissal from the practice for ‘non-compliance’.

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