Patient Acknowledgement of Financial Responsibility & Cancellation/No Show Policies

Cancellation/No Show Policies

When you book your appointment, you are holding a space on the calendar that is no longer available to our other patients who need an appointment. Out of respect to our physicians and to help us best serve all of our patients, we have the following cancellation policy:

• If cancellation is necessary, we require that you contact our office at least 24 hours in advance of your appointment time.
• Appointments cancelled less than 24 hours of the appointment time will be assessed a $25 cancellation fee.
• A “no show” or missed appointment without a 24 hour advance notification will be assessed a $25 “no show” fee.
• The cancellation/no show fees are not billable to your insurance company and will be patient’s responsibility.
• If you are 15 or more minutes late for your appointment, the appointment may be canceled & rescheduled.
• Any and all Cancellation or “No show” fees must be paid prior to booking another appointment.
• Repeated missed appointments may result in the termination of the physician/patient relationship.

Financial Responsibility Policies

• Co-Pays and Deductibles: You must pay your Copay and Deductible at the time of service as required by your insurance company.
• Payments on Account Balances (Copays/Deductibles): You are responsible for the timely payment of your account at the time of your visit.
• I agree to allow Newport Vision Center to charge my credit card on file or any amount not covered by insurance for all services related to my appointment visits including no show or cancellation fees that may apply.