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Financial Appeal Form
Hello, please fill out the following form to request an appeal. A decision will be posted to the client's Simple Practice Portal withing one week of the form being submitted.
7
Questions
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1
Your Name
First Name
Last Name
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2
Client's Name
First Name
Last Name
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3
Clinician Name
First Name
Last Name
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4
Today's Date
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Date
Year
Month
Day
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5
I am requesting an appeal for the following:
Late Cancellation/Missed Appointment Fee
Pause of Services due to Nonpayment
Other
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6
Please describe why you are requesting an appeal.
Please note that appeals are only granted for extenuating circumstances and are at the discretion of Timber Creek's Administrative team.
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7
Signature
I attest that the information above is correct, to the best of my knowledge and that filling out this request is not a guarantee my request will be granted.
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