NO SHOW POLICY
Patients who fail to present for a scheduled appointment without contacting Innovative Pain Management
Clinic at least 24 hours prior to the appointment time will be considered a “NO SHOW’.
__ First offense will result in a warning
__ Second offense will result in a $50 fee not billable to insurance, due before appointment is able to
be rescheduled.
__ Third offense will result in being discharged from the clinic.
__ No-showing for a procedure will result in a $100 fee, not billable to insurance, due prior to the
procedure being rescheduled.
By signing this document you agree to and state that you understand the above policy.
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Patient Signature
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Date
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Patient Printed Name
916 13th Avenue South, Great Falls, MT 59405
406-952-4762(IPMC) or 406-205-1448