Appeals Committee

The Appeals Committee approves appeals on a case-by-case basis. Please fill out the following form to appeal a charge. Once your appeal as been evaluated, the committee will reach out to you via email with the decision.

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First Name *

Last Name *

Phone *

Email *

Please provide the following information regarding the appointment you would like to appeal: Patient name, your relationship to patient (if not the patient), date of appointment, provider appointment was with, a detailed statement as to why the appointment was missed. REMINDER appointments must be cancelled 24 hours PRIOR to appointment time or a $50 no-show fee will be applied to your account. *