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JOHN J. BASILE, MD, PC SUNIL V. PATEL, MD Adult and Pediatric Urology
Dear Sir or Madam, You have an appointment scheduled with Dr. John Basile or Dr. Sunil Patel. We realize that your time is valuable and hope that you realize the time of our doctors and our staff is valuable too. If you are unable to keep your scheduled appointment with Dr. Basile or Dr. Patel, we request that you provide us notification more than 48 hours in advance so that we may provide an opportunity for another patient to seek our urologic services. Our answering service is available after hours to relay any message left for the office. If you do not notify us of your intent to cancel the scheduled appointment no sooner than 48 hours of the appointment, then you will be responsible for an out-of-pocket "no show, no call" cancellation fee of $25 for appointments and $100 for procedures. This fee must be paid in full within ten business days upon receipt of our bill. If your appointment falls on a Monday, we must have your notification of intent to cancel this appointment by no later than the close of business (5 p.m.) on the Wednesday prior to the appointment. If your appointment falls on a Tuesday, we must have notification of intent to cancel by no later than the close of business (5 p.m.) on the Thursday prior to the appointment. We realize that extenuating circumstances do occur and the final decision to assess for this fee is left to the discretion of the doctor. Yours sincerely, John J. Basile, M.D. I have read the above policy and agree to its terms and acknowledge that I will be legally responsible for the prompt payment of the assessed fee. Patient's Signature and Date
Commonwealth Urology
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