The undersigned agrees and authorizes the medical practice to save the credit card information indicated below in the medical record as "card on file" and to make the corresponding charges for the services rendered and/or for the separate time for my appointment in case I do not show up without due cancellation according to the rules of practice that have been provided by means of the document signed by me "Patient Welcome / rules of practice".
Medical Practice: Kameron Health PLLC.
I authorize Kameron Health PLLC medical practice to process the card described above as "Card on file". I understand that this authorization will remain in effect until the account on this credit card expires. The patient can also revoke this form by submitting a written request to the medical practice.
Consent of financial responsibility
Late Cancellation and No-Show to Scheduled Appointment Policy
Thank you for choosing Kameron Health PLLC as your provider for your psychiatric care.
I am committed to providing the best possible care.
Your full understanding of my financial policy is important to our professional relationship and must be signed prior to our first appointment.
Please ask questions if you have any questions about service charges or the financial policy.
Your time is valuable and so is mine. I have reserved time for you and I plan around that reserved time out of respect for your time. When you do not show up for your appointment, you are taking away valuable time that could have been used for someone else who needed to be seen. In addition, I am not a salaried doctor; when you schedule an appointment, you are contracting with me and agreeing to pay for my professional time regardless of whether you use it or not. In other words, it is not the Practitioner's responsibility to pay for your missed or shortened appointment, therefore, you are responsible and you will be billed.