Cancellation Policy/ No Show Policy

Kevin Richardson, D.O.
Orthopedic Spine Surgeon
Cancellation Policy/No Show Policy
1. Cancellation/No Show Policy for Doctor Appointment
We understand that there are times when you must miss an appointment due to
emergencies or obligations for work or family. If an appointment is not canceled at
least 24 hours in advance, you will be charged a twenty-five dollar ($25) fee; your insurance company will not cover this.

2. Scheduled Appointments
We understand that delays can happen however, we must keep the other patients and doctor on time. If a patient is 15 minutes past their scheduled time, we will have to reschedule/cancel the appointment.
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Acknowledgment and Notice of Privacy Practices
Was a notice of Privacy Practices given to the patient or their personal representation?
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Release of Billing Information & Assignment of Benefits

By signing this form, I hereby authorize payment directly to San Antonio Spine Center for any surgical and/or medical benefits. I also authorize San Antonio Spine Center to file all necessary papers to insurance and release any copies of medical records requested by my insurance company for determining benefits. I understand such records may include information regarding HIV/AIDS testing, substance abuse and/or mental health issues.
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Kevin Richardson, D.O.