Debra M. Emmite, M.D.
In order for Dr. Debra Emmite to deliver quality care to you, she has established usual and customary financial and office policies. The following is a list of guidelines that are necessary in order to make your visit as pleasant as possible. Dr. Emmite welcomes comments or suggestions to better meet your expectations and serve your needs.
PLEASE READ ALL INFORMATION AND ACKNOWLEDGE BY SIGNING BELOW.
Dr. Emmite does not accept insurance. All patients must be self pay. If you wish to use your health insurance, you are asked to file it yourself. Dr.Emmite would be classified as a non-preferred provider. Dr. Emmite gives each patient a detailed receipt with her tax identification number, a diagnostic code and a procedure code. The date of service and the payment made will be on each receipt along with Dr. Emmite's signature. Please file this receipt with your insurance according to the policies of your health plan.
- Please arrive at least 10-15 minutes prior to your appointment as to allow sufficient time to complete any necessary paperwork. If you arrive for you appointment more than 15 minutes late, please be aware that there is the possibility that your appointment may be rescheduled, as to not inconvenience the next scheduled patient.
- If you cannot keep your appointment, please call 281.829.5999 to cancel or reschedule your appointment at AT LEAST TWENTY FOUR (24) HOURS IN ADVANCE! Failure to do so will result in cancellation fees equal to that of a missed appointment.
- When an appointment is made with Dr. Emmite, time is specifically allocated for you. When an appointment is missed, or the patient "no-shows", another patient that needed to be seen may have been unable to do so because that time slot was already taken. Missed or "no-show" appointments will be charged.
- Please note that in the event of a missed, rescheduled, or cancelled appointment, your medications may not be refilled.
Additional possible fees:
- A charge of $25 for returned checks, which must be paid prior to your next appointment.
- A charge of $25 for medical records/paperwork requested by the patient. Please make your request one week in advance.
- Lost or expired prescriptions will incur a charge of $10.00 ($15.00 for triplicate prescriptions).
- For phone calls to Dr. Emmite longer than 10 minutes, a charge of $30 may apply.
AT THIS TIME ONLY CHECKS AND CASH ARE ACCEPTED AS FORMS OF PAYMENT.
I understand that I am financially responsible for payment of service and any unpaid balances, and agree with the policies as stated above as set forth by Dr. Emmite.
Parent/Guardian Name (printed)____________________________Date_______________
Patient/Guardian Signature___________________________________________________
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