New Patient Intake Form (Page 3 of 3) in pdf

New Patient Intake Form Page 3

Cancellation Policy:

Velo Sports Rehab appreciates 24 hours prior notice when cancelling an

appointment. If you cancel your appointment with less than 24 hours notice

you will be charged $50.00. If you are more than 10 minutes late to your

appointment we may ask you to reschedule. By signing below, you

acknowledge that you understand and agree to the cancellation policy.

__________________________________

___________________________________

Printed Name

Signature

__________________________

Date

HIPAA (Privacy Practices):

I understand and acknowledge that I have received a copy of the HIPAA/Notice

of Information Practices from Velo Sports Rehab and I understand it entirely.

__________________________________

____________________________________

Signature

Date

Financial Policy:

1. We will bill your insurance company as a courtesy to you. You are

ultimately responsible for your bill regardless of insurance coverage.

Please keep the front desk informed about any changes to your

insurance.

2. Payment for deductible, co-insurance and copay’s are expected at the

time of visit.

3. We do offer a time of service discount to patients that do not have health

insurance.

4. Please don’t hesitate to call or email our office with any questions

regarding your bill.

______________________________

_________________________________

Signature

Date

New Patient Intake Form Page 3