Page 4 - Total Knee Packet

Surgical Cancellation/Reschedule Policy and Fee

Patient Name: ______________________________DOB: ____________________ PID: ______________

Please carefully consider your surgical date before scheduling. Your surgery requires coordination of insurance
authorizations, multiple providers, and facility availability. Rescheduling involves the same level of
coordination and time.

OrthoArizona recognizes that your time is valuable. To help accommodate the medical needs of all patients
within the practice, we require to be notified at a minimum of 10 business days for any cancellation or
rescheduling of a surgical procedure. A $250 cancellation/reschedule fee will be charged if you do not notify
our office at least 5 business days prior to your scheduled procedure. This fee covers administrative costs and
will not be applied toward future visits or patient responsibility. It must be paid before your surgery can be
rescheduled. You will have the option to pay this fee by phone at the time of cancellation. This fee does not
apply if your surgery is canceled due to medical necessity related to your procedure, or if authorization is
denied by your insurance provider.

Occasionally, factors may arise that affect the day, date, or time of your surgery. If this occurs, your surgical
scheduler will notify you as soon as possible.

I have read and understand the information above regarding surgical scheduling and the
cancellation/reschedule policy. I acknowledge that it is my responsibility (or that of the party responsible) to
notify the office at least 10 business days in advance if I need to reschedule or cancel. I understand that
payment is required at the time of cancellation. I also understand that the office will notify me as soon as
possible if a change to my surgery schedule is needed.

Patient / Responsible Party Signature: ___________________________ Date: _______________

OrthoArizona Representative Signature: ___________________________ Date: _______________

Effective 01.01.2024