COMMIT TO A MINIMUM OF ONE ROUTINE APPOINTMENT (S) YEARLY

To provide the quality of care you deserve, we require that all patients have an annual office visit (wellness exam) and annual labs completed once a year. Sick appointments, routine visits and urgent visits are not the same as annual / wellness visits

TARDINESS TO AN APPOINTMENT MAY CAUSE RESCHEDULING OF YOUR APPOINTMENT

In the event that you are 10 minutes late to a scheduled appointment, you may be required to reschedule your appointment.

NO SHOWS / LAST MINUTE CANCELLATIONS / LAST MINUTE RESCHEDULES (LESS THEN 24 HOURS)

If you reschedule, cancel or no show to your scheduled appointment with less than 24 hours notice you may be subject to a $25.00 fee that is the patient's responsibility to pay, not the insurances to pay. You will be responsible for this charge and it will need to be paid before any future appointments can be made.

MEDICATION REFILLS

Our medical staff does their best to get all medication refills sent to the pharmacies as quickly as possible. Keep in mind that this is sometimes done between seeing patients and sometimes at the end of the day. For this reason we do have a 24 to 48 hour turnaround time frame. Please be mindful of your supply of medications to ensure that you do not run out and allow enough time to get the refills sent successfully to the pharmacy.

NO SHOWS/LAST MINUTE CANCELLATIONS/LAST MINUTE RESCHEDULES:

Providers and staff of Quick Primary Care, PA relies on the pre-scheduled appointments to plan their day to day activities. Last minute reschedules or cancellations and no shows disrupt the daily flow. If you have to cancel or reschedule your appointment, please provide us with at least 24 hour prior notice. If less than 24 hours notice is not given we may charge a $25.00 fee directly to you. Please note that this charge will not be billed to any third party (your insurance) but directly to you and you will be responsible for payment of this charge prior to any further appointments.

RETURNED CHECK:

Checks returned to Quick Primary Care, PA by the bank will be assessed a return check fee, in addition to the original amount of the check. You have ten (10) days to clear up the outstanding check. If you do not pay the check plus the returned check fee in the specified time the check will be sent to the State's Attorney's Office for further collection.

COLLECTION AGENCY:

In the event your account becomes delinquent and is turned over to a collection agency or attorney, you will be financially responsible for all associated collection fee(s) and legal fee(s) that Quick Primary Care, PA incurs through the process utilized to collect the delinquent balance. Please be aware if your account is turned over to a collection agency you can be discharged from our practice.

PAYMENT:

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some insurance companies pay fixed allowances for certain procedures and others pay a percentage of the charges. I understand that it is my responsibility to pay any deductible amount, co insurance or any other balance not paid for by my insurance or third party payer. Quick Primary Care, PA and all its subsidiaries are covered under this document.

By initialing and signing this form, I am in agreement with the above terms, or understand the office policies.