Cancellation Policy Cancellation Policy FILL AND SUBMIT PRINT AND FILL FILL AND SUBMIT Procedure/Clinic Visit Cancellation and Reschedule PolicyAt Diablo Digestive Care, Inc., our goal is to provide quality care in a timely manner. In regards to procedures, we request notification via phone at least 48 hours in advance if you are unable to keep your appointment. In regards to clinic appointments, we request notification via phone at least 24 hours in advance if you are unable to keep your appointment. If you fail to appear for your scheduled appointment/procedure, or if you do not notify us by phone of your inability to keep your scheduled visit, the time that has been allotted for your visit may not be utilized by another patient and will result in a loss of time and resources. Our Cancellation/Rescheduling Policy We request that you please give our office a 48 hour notice in the event that you need to cancel or reschedule your procedure and a 24-hour notice in the event that you need to cancel or reschedule your clinic visit. This will allow us to make the appointment time available to someone else. Our office number is (925) 363-0069 If you miss your procedure or do not contact us with at least 48 hour prior notice, we will consider this to be a missed procedural appointment and a $200 fee will be assessed to you. If you miss your clinic visit or do not contact us within 24 hour prior notice, we will consider this to be a missed clinical appointment and a $50 fee will be assessed to you. This will NOT be billed to your insurance. Consent(Required) I have read and understand the Procedure/Clinic Visit Cancellation and Reschedule Policy and agree to be bound by its terms.(Required)Signature (Patient or Legal Guardian)(Required)Relationship to Patient(Required) Printed Name(Required) Date(Required) DD slash MM slash YYYY It is your responsibility to notify our office if your insurance changes prior to your scheduled procedure date. If insurance is not updated prior to your procedure, you will be fully responsible for the cost of the procedureInitial(Required) Date DD slash MM slash YYYY Please note: Our office does not verify benefits. It is the patient’s responsibility to know what their cost share/deductible/co-pay will be for procedures. We are only responsible to obtain authorization for the procedure. Please call your insurance company if you have any questions regarding your cost share of the procedure.CAPTCHA PRINT AND FILL Downlaod Form
