Karl Hafner MD
98 N Second St
Fulton, NY 13069
Suboxone Deposit
Date: _________________
Name: _________________________
Dear Patient,
This serves as an explanation of how our Suboxone deposit works. To enter our Suboxone program a $50 deposit is required. Your deposit is $50 as cash or money order only. Once you have come to your first THREE appointments with NO CANCELLATIONS, NO RESCHEDULES, NO NO- SHOWS and if you have insurance once they have paid for their portion of your visits you will have your deposit refunded. You must also arrive to your appointments on time not after the stated appointment time. You may use your deposit towards future visits once you are eligible to receive it. If someone else has made your deposit it will be refunded to that individual and may not be put towards future visits. If your insurance requires a copay it must be made the day of your visit before you are seen. We do not accept some insurance plans. It is your responsibility to have verified this before the visit date. If we do not take your insurance you will be required to pay at the time of your visit. Please mail this to our office along with a copy of a government issued ID that has your signature on it. Once we have received the DEPOSIT, your ID and have a working phone number we will call you and setup an appointment. This deposit will NOT be refunded if you choose to not be seen or are abusive or threatening in any way.
You must bring a government issued ID and current insurance card to all visits.
Patient Signature:_____________________________________
Contact Phone number_______________________________
Witness signature:_____________________________________________
Please make sure you have included a copy of your ID and verify that your DEPOSIT both are in the envelope
98 N Second St
Fulton, NY 13069
Suboxone Deposit
Date: _________________
Name: _________________________
Dear Patient,
This serves as an explanation of how our Suboxone deposit works. To enter our Suboxone program a $50 deposit is required. Your deposit is $50 as cash or money order only. Once you have come to your first THREE appointments with NO CANCELLATIONS, NO RESCHEDULES, NO NO- SHOWS and if you have insurance once they have paid for their portion of your visits you will have your deposit refunded. You must also arrive to your appointments on time not after the stated appointment time. You may use your deposit towards future visits once you are eligible to receive it. If someone else has made your deposit it will be refunded to that individual and may not be put towards future visits. If your insurance requires a copay it must be made the day of your visit before you are seen. We do not accept some insurance plans. It is your responsibility to have verified this before the visit date. If we do not take your insurance you will be required to pay at the time of your visit. Please mail this to our office along with a copy of a government issued ID that has your signature on it. Once we have received the DEPOSIT, your ID and have a working phone number we will call you and setup an appointment. This deposit will NOT be refunded if you choose to not be seen or are abusive or threatening in any way.
You must bring a government issued ID and current insurance card to all visits.
Patient Signature:_____________________________________
Contact Phone number_______________________________
Witness signature:_____________________________________________
Please make sure you have included a copy of your ID and verify that your DEPOSIT both are in the envelope