• NO-SHOW & APPOINTMENT CANCELLATION POLICY ACKNOWLEDGMENT

  • PATIENT INFORMATION

  • Date of Birth:*
     - -
  • Date:*
     - -

  • OUR COMMITMENT TO YOUR CARE

  • At Allied Comfort & Care, committed to providing timely, high-quality behavioral health services to all patients. Missed appointments and late cancellations limit access to care for other patients and impact continuity of treatment. Please review and acknowledge the following policy.

  • FEES

  • Patients may be charged the following fees:
  • Patients may be charged the following fees:
    APPOINTMENT TYPE FEE
    Therapy Session Up to $50
    Psychiatric Evaluation Up to $75
    Medication Management Up to $50
  • Fees may be waived at the discretion of management for emergencies or documented circumstances beyond the patient's control.

  • APPOINTMENT CANCELLATION POLICY

  • Patients are required to provide at least 24 hours' notice when canceling or rescheduling an appointment. Notice may be provided by:
    • Calling the office at 215-989-1771
    • Leaving a voicemail after business hours
    • Using approved patient communication methods

  • REPEATED NO-SHOWS

  • The following actions may occur:

  • LATE CANCELLATIONS

  • A late cancellation is defined as:
    • Canceling an appointment with less than 24 hours' notice.
    Repeated late cancellations may result in:
    • Review of treatment participation
    • Scheduling restrictions
    • Administrative review of services
  • 1 FIRST NO-SHOW
    • Appointment documented.
    • Courtesy reminder provided.
  • 2 SECOND NO-SHOW
    • Clinical review of attendance.
    • Discussion regarding barriers to treatment.

  • NO-SHOW POLICY

  • A No-Show occurs when:
    • A patient does not attend a scheduled appointment.
    • A patient arrives more than 15 minutes late and cannot be accommodated.
    • A patient fails to log into a scheduled telehealth appointment within 15 minutes of the scheduled time without contacting the clinic.
  • 3 THIRD NO-SHOW
    • Administrative review.
    • Possible discharge from services due to non-compliance with attendance requirements.

  • TELEHEALTH APPOINTMENTS

  • Patients receiving telehealth services responsible for:
    • Being available at the scheduled appointment time.
    • Testing internet and device functionality before the appointment.
    • Providing updated contact information.
    Technical difficulties should be reported immediately to the clinic.

  • ACKNOWLEDGMENT

  • I acknowledge that I have read and understand the Allied Comfort & Care No-Show and Appointment Cancellation Policy. I understand that failure to comply with this policy may result in fees, scheduling restrictions, or discharge from services. I agree to notify the clinic as soon as possible if I am unable to attend a scheduled appointment.

  • EMERGENCY EXCEPTIONS

  • Fees may be waived for:
    • Medical emergencies
    • Hospitalization
    • Family emergencies
  • Date:*
     - -
    • Severe weather conditions
    • Technology failures beyond the patient's control
    • Other circumstances approved by clinic management
  • Date:
     - -
  • Documentation may be requested.
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  • Should be Empty: