CSMA Sleep Study Patient Forms

Dear Patient:

We strive to render excellent medical care to you and the rest of our patients. In an attempt to be consistent with this, we have implemented an Appointment Cancellation / No Show Policy that allows us to schedule appointments for all patients in an efficient fashion. When an appointment is scheduled, that time has been set aside for you. When patients do not utilize their appointments as scheduled this hinders the ability of our office to serve other patients and creates wasted resources that become costly.

We require a minimum* of 24 HOURS notice prior to the time of your scheduled appointment if you must cancel your appointment. If a patient misses an appointment without contacting our office, this is considered a missed appointment (“No-Show, No-Call”). A non-refundable fee of $50.00 will be charged to you for a missed appointment or if you do not notify our office to cancel your scheduled appointment at least 24 hours prior to your appointment time. If a patient accumulates a total of three (3) missed appointments, the patient may not be rescheduled for future appointments and may be asked to leave our practice. *For appointments scheduled on Monday, the deadline for canceling your appointment is 12 Noon Friday prior to your Monday appointment.

We require notification by 12 Noon the day before* your scheduled sleep study appointment if you must cancel your sleep study. *For sleep studies scheduled for Sundays or Mondays, the deadline is 12 Noon on the Friday before. *For sleep studies scheduled around the time of Holidays, the deadline will be specifically noted at the time you schedule your appointment.  A non-refundable fee of $250.00 will be charged to you for a missed appointment (“No-Show, No-Call”) or if you do not notify our office to cancel your appointment according to the guidelines stated in this paragraph.

Any cancellation/no show fee will be billed to you. This non-refundable fee is the responsibility of the patient and will not be covered by your insurance company. These fees are considered a fine for not utilizing the slot set aside for your appointment or sleep study.

If emergency circumstances occur causing you to miss your scheduled appointment and you are unable to cancel according to our policies stated above, we will require verification of the emergency circumstances and we will determine on a case-by-case basis if the fee will be waived. If you do not successfully follow through with a rescheduled appointment at a later date then no consideration will be granted to waive the fee.

If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have.

We thank you for your patronage.

ALL fields marked with * are mandatory. Pressing “Submit” will automatically email the form to Comprehensive Sleep Medicine Associates (CSMA). All information is strictly confidential.

Contact Us