No Show Policy Form

Thank you for choosing Concordia Mind Health for your medical needs. We appreciate and value your trust in our care. Effective July 1st, 2022, our clinic will be implementing a new cancellation/no show policy. Any new or established patient who fails to attend or cancel appointments within 24 hours will result in an automatic withdrawal of the following fee.

Due to high patient demand and limited availability, Concordia Mind Health will now be enforcing a no-show charge for appointments that are not canceled 24 hours in advance

New patient evaluation that is not canceled or left unattended will be an automatic withdrawal of $100
Established evaluation that is not canceled or left unattended will be an automatic withdrawal of $50.

No Show Policy

Patient Name:

Date of Birth:

Failure to abide by the above agreement will result in an automatic withdrawal of the appropriate amount. As a patient, I understand I will be charged an automatic withdrawal fee for failure to appear or cancel my scheduled appointment. Email and paper receipts will be provided 7 to 10 business days following the charge. Failed appointments are not covered by insurance.

I understand

It is my understanding that Concordia Mind Health will bill my insurance company and I will be responsible for any fees not covered. Rather using health insurance or private pay rates, I agree to make the necessary payment required by my insurance company or clinic self pay rate at my time of service. Unless alternative arrangements have been previously made.

I understand

I authorize Concordia Mind Health to send me electronic billing statements.

I authorize

Signature

Clear

By signing the agreement above you are authorizing Concordia Mind Health to charge
outstanding balances and appointment fees on my account to the following card:

Name on card:

Card number:

Expiration Date:

CVV:

Billing zip code:

Signature

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