Home - Huntington Family Medicine
Huntington Family Medicine
50 Bellefontaine St Suite #403
Pasadena, CA. 91105
Office Policies
Patient Name:____________________
Patient DOB:______________
• Huntington Family Medicine requires 24 business hours (Monday-Friday) notice for appointment cancellations. Otherwise the patient will be charged a $25.00 dollar fee for missed appointments.
Initial: _____
• It is the patient’s responsibility to know the date and time of his/her appointment. Appointment reminder calls are a courtesy.
Initial: _____
• The office will verify the patient’s medical benefits; however, this is not a guarantee of payment. It is the patients responsibility to know his/her benefits including deductibles, co-pays, and visit limitations. In addition, it is the patient’s responsibility to keep track of visits used during his/her benefit year.
Initial: _____
• We require copayments at the time of service.
Initial: _____
• Please notify Huntington Family Medicine in a timely manner of any changes including: insurance coverage, address and telephone number. Delay in providing us with accurate insurance information may prevent insurance reimbursement, and the patient will be responsible for fees.
Initial: _____
• There is a $25.00 dollar fee for patients requesting their medical records.
Initial: _____
• There is a $10.00 dollar fee for forms such as: DMV, disability, handicap placard, sports, school, work, camp physicals, FMLA, private medical disability, life insurance, jury duty, Ect.
Initial: _____
I have read, understand and will abide by the office policies
Signature: ________________________ Date: ______________________
(Parent/Guardian if patient is a minor)
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