Office Policies Form

Please fill out and submit the form below prior to your appointment date / time. You may also download and print the form to manually fill it out and bring it with to your appointment using this link: DOWNLOAD FORM

OFFICE HOURS

Monday through Thursday 8:30 am to 3:30pm (some evening hours may be available)

 

OFFICE VISITS

  • Scheduling:  You must have a scheduled appointment to be seen. Schedule an appointment by calling the office at 928-776-7400. You may also request an appointment by email at [email protected], please include contact information. For new patients there is a one- time scheduling deposit of $50.00 for evaluations which is due prior to your appointment. This will be applied to your fee on the day of your appointment. Deposit is non-refundable should you miss your appointment.

  • Missed or late cancelled appointments: Your treatment is important to us which is why our doctors schedule time just for you. You must notify the office at least 24 hours before you appointment or you will be charged 50% of the appointment fee, even if you do not receive a reminder call. Fees must be paid before additional appointments are scheduled. After two missed appointments it is our policy to dismiss you from the practice and ask you to find a new treatment provider.

  • We do not participate in, and we do not file, any insurance. Your office receipt will contain the necessary information for you to file your own insurance. 

  • We have opted out, and do not file Medicare. Medicare requires that you sign a private contract with our office at the time of your first visit. By signing this form you are acknowledging that you are willing to receive services from an opted out provider and will not bill Medicare for reimbursement. 

  • Full payment is expected at the time of service. Cash, check, debit and credit cards (Visa and MasterCard) are accepted. 

PRESCRIPTION REFILLS

  • If you are prescribed medication, you will be provided an initial prescription and refills to last until the suggested follow-up visit. It is your responsibility to schedule your follow-up appointment before the prescription runs out to ensure a continued supply of medication.

  • Medication refills will be denied if you fail to keep follow up visits.

  • CALL YOUR PHARMACIST for refills. Your pharmacists will contact the office if a refill needs to be authorized. 

SERVICES SUBJECT TO CHARGE

  • Telephone consultation, request for records, prescription refills, missed appointments, and late cancellations.

  • Completion of form letters and/or reports if not done during your appointment. Fees will be charged at office staff/medical staff hourly rate.

EMERGENCY / AFTER HOURS

  • Should you experience a life threatening medical emergency please immediately call 911 or go to the nearest hospital emergency room.

 


I have read and understand the information listed above and received a copy.