QPC New Patient - Page 6

Quick Primary Care

Office Policy Agreement - Page 6 of 9

Yearly Routine Appointments

AUTHORIZATION TO DISCUSS CARE WITH FAMILY MEMBERS/FRIENDS

I authorize Quick Primary Care to discuss my medical care with family members or friends I designate when I am present or when I have provided written or verbal permission, in accordance with applicable privacy laws.

To Request Appointments

AUTHORIZATION TO COMMUNICATE VIA TEXT/EMAIL FOR SCHEDULING PURPOSES

By checking this box, I consent to receive text messages and emails from the office for appointment scheduling, reminders, and related administrative communications. Standard message and data rates may apply.

Appointments/No-Shows/Cancellations

NO-SHOWS, LATE CANCELLATIONS, AND LATE ARRIVALS FOR APPOINTMENTS

I understand that I must provide at least 24 hours' notice to cancel or reschedule an appointment. Missed appointments, late cancellations, or late arrivals may result in fees and may limit future scheduling availability.

Professional Fees

FINANCIAL RESPONSIBILITY

I understand that I am financially responsible for all charges for services rendered, including copayments, deductibles, coinsurance, and non-covered services. Payment of applicable amounts is due at the time of service unless other arrangements have been made in advance.

No-Show Policy

NO-SHOW POLICY FOR ALL NEW AND ESTABLISHED PATIENTS

A "no-show" is defined as failing to arrive for a scheduled appointment without providing required advance notice. Repeated no-shows may result in discharge from the practice or restrictions on scheduling future appointments.

Returned Check Policy

RETURNED CHECKS

I understand that returned checks are subject to a $35.00 returned-check fee, in addition to any bank charges. Future payments may be required by cash, credit card, or other guaranteed form of payment.

Collection Agency

COLLECTION POLICY

I understand that delinquent balances may be referred to a collection agency. I am responsible for all collection costs, including reasonable attorney fees and court costs, as permitted by law.

HIPAA

HIPAA

I acknowledge that I have been offered the Notice of Privacy Practices describing how my protected health information may be used and disclosed, and how I may access my information.

Agreement

By initialing and signing this form, I acknowledge that I have read and agree to all the office policies.