Clarity Eye Care No Show Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. In addition, if there is a 20% no show rate, we must in turn “overbook” by 20%. As a result, the waiting area becomes crowded and waiting times as well as stress levels increase. Therefore, Clarity Eye Care reserves the right to charge a fee of $40 for all missed appointments ( “no shows” ) and appointments which, absent a compelling reason, are not cancelled with at least a 24 hour advance notice.

The CMS (Center for Medicare Services) authorizes physicians and suppliers to charge a missed appointment fee to Medicare patients provided that they also charge non-Medicare patients the same fee. Therefore, “No Show” fees will be directly billed to you (the patient). This fee is not covered by insurance and must be paid prior to your next appointment. Multiple “no shows” in any 12 month period may result in termination from our practice.

I have read and understand the above policy (sign/date) _____________________________________________

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HIPAA Privacy

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I ______________________________________________ [Please print full legal name] (the “Patient” or “Patient's legal representative) have been presented with the Notice of Privacy Policy (the “Policy”) of Clarity Eye Care (the “provider”), and have been offered a copy of such policy to keep for my records.

_______(please initial here) I hereby acknowledge that I have been provided with a copy of the policy

_______(please initial here) I hereby refuse to acknowledge receipt of the Policy. I understand that even through I may refuse to sign this acknowledgement, Provider may still provide treatment for me

Signature/Date ______________________________________________________________________

OFFICE USE ONLY

I ________________________ acting as ______________________ (please print relationship to or official position with Provider) for Provider attempted to obtain the written acknowledgment of receipt of the policy of Provider on ___________ (insert date attempt was made), but acknowledgment could not be obtained because

_________ (intial here) Patient or Patient's legal representative refused to sign

_________ (initial here) Patient or Patient's legal representative could not be communicated with sufficient to obtain acknowledgment

______(initial here) Emergency circumstances prevented securing acknowledgment

______ (initial here) Other (please specify) : _____________________________________________