No-Show/Cancelation fee Dispute request

Did you get charged with a no-show or late cancelation fee but wish to dispute the charge due to extenuating circumstances? Fill out the form below for our management team to review. We will be in contact via email or phone within 48 hours.

Filling out this form does not guarantee that the fee will be reduced or waived. Each request will be reviewed individually based on the information provided, the patient's attendance history, and the circumstances surrounding the missed appointment.

All no-showed appointments and cancelations within 24 hours of an appointment are subject to the $60 fee. If you have incurred a charge, you have already had one fee waived as we allow one grace no-show or cancelation per case.

No-show/Cancelation Fee Dispute Form

Phone

(360)714-0870

info@performancephysicaltherapy.com

First Name

Last Name

Birthday

Phone

Date of Missed Appointment required

Reason for Dispute

Explanation of Reason

When did you first become aware that you would not be able to make the appointment?

Did you attempt to contact the office? Required

Yes

If yes, how did you contact us?

Details

Supporting Documentation

Supporting documentation is not always required, but it may help the clinic evaluate your request. Please do not provide detailed medical records or other sensitive information unless specifically requested.

PATIENT ACKNOWLEDGMENT

By signing below, I acknowledge and understand the following:

Performance Physical Therapy reserves appointment times specifically for each patient.
Missed appointments and late cancellations may prevent another patient from receiving care.
Submitting this request does not automatically suspend, remove, or waive the fee.
My request will be reviewed based on the circumstances described, any available documentation, my previous attendance history, and the clinic’s cancellation policy.
The clinic may contact me if additional information is needed.
Approval of a dispute applies only to the specific fee identified on this form and does not change the cancellation policy for future appointments.
Repeated no-shows or late cancellations may result in additional fees, limits on future scheduling, or discharge from care in accordance with clinic policy.
The information I have provided is accurate and complete to the best of my knowledge.

Your Signature

Thanks for submitting!