This PUSH form is not secure. There are risks associated with sending protected health information through an insecure form. By sharing your protected health information through this form, you are accepting these risks.

- The appeal process can take up to 30 business days before a decision is made.

- There is no guarantee that the appeal process will result in a reversal of the $25.00 No Show/Late Cancel fee.

- Appeals must be submitted within 30 days of the scheduled appointment to be considered.

- Appeal form only applies to PUSH appointments. No shows for CAPS and Nutrition must be discussed with them.

By checking the box below, you agree to accept the risk of sending your protected health information through an insecure form.
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