Policies Page
Below you will find our policies and procedure for care at our facility.
Appointment Scheduling
Due to the overwhelming requests for consultations, there is a 24-business-hour cancellation policy. We encourage patient responsibility with their appointment schedule. Scheduling reminder calls are a courtesy and is NOT meant to replace your management of our appointment schedule. Please don’t depend on the reminder calls as your only means of arriving at your appointment. The charge for Late Canceled Appointments and NO-show appointments are charged $25 per appointment. Twenty-four business hours advance notice is required and cancellation for a next-day appointment left on voicemail after business hours will be charged as a late cancellation. If you are canceling a Monday appointment you are required to call on Friday. You may cancel your appointment by calling.
Cancellation Policy
As a courtesy to my other patients and to me, please provide adequate notice (24 business hours for follow up appointments and 48 business hours for new patient appointments) if you need to cancel or change an appointment. We often have a waiting list and, because we do not double book rooms, your appointment time cannot be used by anyone else if you cancel on short notice or do not show up.
As indicated in the office policies that you agreed to prior to your first appointment:
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Cancellations without adequate notice or no-shows will be subject to a missed appointment fee of $25.00 for follow-up appointments and $20.00 for new patient appointments or forfeiture of the prepaid service.
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True emergencies are an exception to this policy. Please note, however, that work and school-related demands are not considered emergencies.
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Patients who habitually arrive late, fail to show up, or cancel on short notice will be dismissed from the practice.
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If you are more than 15 minutes late for your appointment, you will have to reschedule and will be charged a late cancellation fee.
We do not want missed appointment fees to be an impediment to your care and so we ask for your mutual respect when you make an appointment we block out our schedule for you and ask that you exercise the same consideration when planning your calendar.
Thank you for your respect and understanding.
Insurance Verification – Please Read Carefully
**Verification of coverage is not a guarantee of payment. [xxxxx] is not responsible for any mis-quotes of benefits. Your patient responsibility will be processed according to the explanation of benefits received from your insurance company.
**It is recommended that you call your insurance company, prior to your visit, to verify your benefits. [xxxxxx] is not responsible for checking patient benefits, including any additional lab work or diagnostic imaging. If you have not called your insurance company to check coverage prior to your visit, you must pay in full for services rendered. We advise that, prior to getting any lab work done, or having any radiological imaging performed, that you check your insurance coverage. A radiological imaging or laboratory requisition form does not guarantee coverage. Our billing department will send you an invoice for any visits denied by your insurance company.
**You will be expected to pay your co-pay at each visit, and for any supplements. We do not bill for co-pays. Please be prepared to bring your co-pay to every visit, and stop at the front window to make payments, even if you are not asked to do so.
Patient Financial Responsibility
Thank you for choosing Allegiant Health and Associates as your healthcare provider. We are committed to providing you with quality and affordable health care. Please review and sign this policy, asking questions as necessary. A copy of this document will be offered to each patient.
1. Registration: All patients shall complete the Patient Information form, which will be used to ensure accurate information for proper billing. We must obtain a copy of your photo ID and current valid insurance card in order to validate your coverage. If you fail to provide us with the correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you will be responsible for the balance of a claim.
2. Patient Payment: All patient payments are due at the time of service. This includes co-payments and deductibles. This arrangement is part of your contract with your insurance company. If we are not able to verify insurance, you will be responsible for payment at the time of service.
3. Insurance Plans: We accept assignment and participate and file most insurance plans. Your insurance may not cover all services and knowing your insurance benefits is your responsibility. Please contact your insurer with any questions regarding your coverage to receive the maximum benefits
4. Claims: We will submit your claim based upon service provided at the time of your visit. Your insurance company may request additional information from you. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether your insurance company pays or not. Your insurance benefit is a contract between you and your insurance company; we are not party to your insurance contract.
5. Self-Pay Patients: We offer a prompt payment discount to our patients who do not have insurance or for non-covered services.
6. Credit and Collection: If your account is past due, you will receive a statement with your balance due. If a balance has remained unpaid, it will be sent to a collection agency.
7. Missed Appointments: There is a $25.00 charge for missed appointments. If you need to cancel your appointment, please notify our office at least one business day or as soon as possible so that your spot may be filled by another patient needing to be seen, prior to your appointment. These charges will be your responsibility and billed directly to you. Please help us serve you better by keeping your regularly scheduled appointment.
8. Forms: There are charges for the completion of certain forms.
9. Assignment of Benefits: I hereby agree to assign and transfer to Allegiant Health & Associates all benefits and payments now due and payable or to become due and payable to me under any insurance policy or benefit plan or program for this visit and outpatient care. I have read and understand my financial responsibilities and agree to the guidelines.
Social Media Consent/Release Form
For News/Social Media, Promotional Materials, Written Articles, Research and/or Photographs
I hereby authorize Allegiant Health & Associates to use my photo and/or name related to my experience with Allegiant Health & Associates. I understand this information may be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, media, and other similar ways Ultimate Hydration and Wellness Clinic disclose to me or my legal representative, where appropriate, the specific information and/or photo to be used prior to release in the social media.
My consent is freely given as a public service to Allegiant Health & Associates expecting payment. I release Allegiant Health & Associates and their respective employees, officers, and agents from any and all liability that may arise from the use of such news, media stories, promotional materials, written articles, videotapes, and/or photographs.
I understand that I can revoke this release at any time in writing and that the use of any of my photos or other information authorized by this release will immediately cease.