48-Hour Cancellation Policy
For each Medical-Legal appointment the provider reserves an extended amount of time in their schedule to spend with the injured worker. Prior to the evaluation, the provider also reviews past medical records. Finally, this office complies with the the obligatory appointment notifications.
For these reasons, if the injured worker fails to show up for the evaluation, or to cancel or reschedule this medical-legal evaluation by the date noted in the table above, a missed appointment fee will be charged as follows:
ML 100 $500.00 - Missed Appointment for a Comprehensive or Follow-Up Medical-Legal Evaluation.
By signing below, you agree to honor this cancellation policy and to reimburse the provider the amount above should the injured worker fail to show up at the scheduled appointment or to cancel or reschedule by the date noted in the table above.
Please sign and fax this cancellation to the following fax number: ________________ .
Signature: Print Name: