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Giles & Associates Appeal
Please fill out the form below to formally appeal a No-Show-Fee (NSF). Once a decision is made you will be notified via email. Please appeal only one appointment per form submission.
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Patient First Name
Your answer
Patient Last name
*
Your answer
First Name (if not the patient)
Your answer
Last name (if not the patient)
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Relationship to patient (if not the patient)
Parent or Guardian
Spouse
Other:
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Email Address
*
Your answer
Date of appt being appealed
*
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DD
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YYYY
Brief description of why the appointment was missed or canceled within the 24/hr cancelation period.
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