1. Appointment Policies
- I agree to arrive 15 minutes before my scheduled appointment time
- I understand that arriving more than 15 minutes late may require rescheduling
- I will provide at least 24 hours notice for cancellations
- I acknowledge that three missed appointments without notice may result in discharge from the practice
2. Communication Guidelines
- I understand that routine matters will be addressed during regular office hours
- I will use the patient portal for non-urgent communications
- Emergency situations require calling 911 or visiting the nearest emergency room
- After-hours calls are reserved for urgent medical concerns only
3. Prescription Policies
- Medication refills require 48-72 hours' notice
- Controlled substance prescriptions:
- Require in-person visits every 3 months
- Cannot be refilled early or replaced if lost
- Are subject to random drug screening
4. Financial Responsibilities
- I agree to pay all copayments at the time of service
- I will maintain current insurance information with the practice
- I understand that unpaid balances may result in referral to collections
- I am responsible for knowing my insurance coverage and limitations
5. Medical Records and Privacy
- I acknowledge receipt of the Notice of Privacy Practices
- I authorize the release of medical information for treatment and billing
- I understand that medical record requests require 7-10 business days
6. Patient Rights and Responsibilities
- I will provide accurate and complete medical history
- I agree to follow the recommended treatment plan
- I will ask questions when I don't understand my care
- I will treat staff with respect and courtesy
Signatures
Patient Name: ___________________ Date: ___________
Provider Name: __________________ Date: ___________
Witness: _______________________ Date: ___________