AUTHORIZATION & NOTICE OF PRIVACY PRACTICES

First Name:

Last Name:

Email:

Phone:

I understand that my private healthcare information is protected under HIPAA Privacy Regulations.

*May we leave a message for you on your answering device?

I fully understand that my signature is consent and authorization to be examined by the Lifelong Balance medical team.

I understand that my entire patient history will remain completely confidential and will not be released without express written consent from me.

Date:

CANCELLATION AND NO-SHOW POLICY

We understand that situations arise in which you must cancel your scheduled appointment. It is therefore requested that if you must cancel your appointment you provide a 24-hour notice. Appointments which are cancelled within less than 24-hour notice may be subject to pay the full balance owed at the time of cancellation. Cancellation and no-show fees are the sole responsibility of the patient and must be paid in full before the patient's next appointment.

We understand that unavoidable circumstances may cause you to cancel with less than a 24-hour notice, fees may be waived upon management approval.

Our practice firmly believes that good physician/patient relationships are based upon understanding and good communication. Questions about cancellation and no-show fees can be directed to the front desk at (603) 380-9159.

Please sign that you have read, understand, and agree to this cancellation and no-show policy.

Patient Name:

Date: