Cancellation Policy Form

 

Confidentiality:  As a patient of Dr. Alex Kaminsky, you have certain privacy expectations as well as rights and our clinic is fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security rules for health care providers.  We understand the importance of privacy and are committed to maintaining the confidentiality of your medical information.  We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.

 

Office of Dr. Alex Kaminsky, Unique Care Chiropractic, P.C.

We understand that situations may arise where a patient must cancel their appointment. Therefore, we kindly request that if you must cancel your appointment, please provide us with at least 48 hours advanced noticed. Patients who fail to cancel their appointment up to a 48 hour advanced notice, as well as “no-show” patients are subject to a cancellation / No-Show fee. Cancellation/No-Show charge is the sole responsibility of the patient and must be paid in full. We ask for your cooperation in guaranteeing our mutually respectful relationship by writing down your credit card information below: Thank you for your cooperation and understanding as we strive to best serve the needs of our patients. Appointment to be confirmed by email. Cancellation Fee $150 By signing below you acknowledge that you have read and agree to this policy.

Submit Confidential Form (Thank you, submit form and we will print out for you to sign at our office)

Signature:
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