Treatment Consent HIPAA Telehealth Informed Consent Service Agreement Medical History PCP Release of Information Adult Psychosocial Child Psychosocial Payment Authorization Document Submission Insurance Submission Appeal Appeal of No-Show / Late Cancellation Step 1 of 2 50% First Name* First Last Name* Last Phone*Email* Office Location*Choose OneBay CityGrosse PointeMidlandMount ClemensPort HuronSaginawWho's your therapist/doctor?*What are you appealing?*(Check all that apply) First No-Show/Late Cancellation Case Closure (2 missed appts) Appeal of Fee Charged How many appointments have you missed that you are appealing?*Choose OneOneTwoDate of no-show or late cancellation in question* Date Format: MM slash DD slash YYYY Date of no-show or late cancellation in question* Date Format: MM slash DD slash YYYY Per our policy explained within our Treatment Consent document given to you at intake and the Service Agreement you signed, it was explained that it is our policy to charge a minimal fee for missing your appointment if you did not give 24 hours notice. Please understand that this is not meant to be punitive, but we are asking you to help cover our lost billings for the time you missed. This form gives you an opportunity to explain your situation and appeal your charge with the Renewal Director. If you have two or more "No-Show" appointments you are being asked to give us a plan of correction before being allowed to schedule more appointments. * Please be aware that you must submit this form within 60 days of the date of the missed appointment or your appeal will automatically be rejected. Please explain your reason(s) for missing your scheduled session(s) and what you are asking for?*What is your plan to more consistently attend your scheduled sessions in the future?Do you receive our appointment reminders via text, email, or call?*Choose OneYesNoWhy not?*Are you confirming your appointments when you receive them?*Choose OneYesNoWhy not?*Signature*Date* Date Format: MM slash DD slash YYYY * Office Use Only *Number of NS/CAClinician's Response:Nurse Practitioner's Response:Appeal Manager's Response: Copyright 2020 © Renewal Christian Counseling Center
