WITHDRAWAL MANAGEMENTAND INITIAL OFFICE VISIT
WITHDRAWAL MANAGEMENT AND INITIAL ADDICTION MEDICINE VISIT
All initial consultation visits, including withdrawal management visits, consist of :
- a comprehensive review of medical and psycho-social history
- physical exam - currently limited due to virtual visits
- laboratory referrals and urine testing is referred out
- treatment planning
- coordination of care
Initial office visits are usually 60-90 minutes long. Follow-ups are 40 minutes.
It is not guaranteed that medications, such as buprenorphine will be prescribed at the first visit without full evaluation and examination of prior prescribing history.
Anticipate that the acute phase of withdrawal process will last up to seven days and it is not unusual to take off from work and have assistance from family and friends during this time.
It is important to rest when in withdrawal (which can be protracted), just as you might after any significant medical procedure. Wanting to be “fixed, better and back to functioning” is a worthy aspiration which will happen; however, rushing the recovery process does not enable lasting integration of recovery skills that help prevent return to harmful or problematic use.
Take the time to mend, if you remain abstinent, you will not have to go through withdrawals again.
ALCOHOL WITHDRAWAL MANAGEMENT
Alcohol withdrawal management may be life threatening and requires close medical monitoring and supervision. The elderly and those with a history of alcohol withdrawal seizures, hallucinations, delirium tremens, prior hospitalization for severe withdrawals, or significant cardio-vascular disease should seek inpatient (hospital) care as the recurrence of a life threatening, complicated withdrawal is high.
However, the majority of individuals wishing to withdrawal from alcohol may be treated on an outpatient basis, in an office setting. The most concerning risk of outpatient alcohol withdrawal medication management is an accidental over-dose with the medications given to treat withdrawal symptoms, especially when mixed with alcohol or opioids during a relapse while attempting to go through a withdrawal process. This situation could be fatal.
For your safety during withdrawal treatment from alcohol, you must provide the contact of a companion (friend or relative) to all of the office visits (in person or virtually) associated with your withdrawal process. This person will be responsible for monitoring your medications and calling the treating physician in the event of any complications, as well as inquiring about any adjustments in the dose of medications.
Your personally tailored withdrawal regimen will be explained to you and your companion; side effects and the risk and benefits of the medications, along with what may happen should you choose not to take the medications will be explained as well. If you consent to treatment, medications will be prescribed.
Patients undergoing alcohol withdrawal treatment will be given a phone number to call for urgent issues related to withdrawals that may be used after office hours until 10 pm. For medical emergencies please call 911 or go to the nearest emergency room.
OPIOID WITHDRAWAL MANAGEMENT
Dependency on opioids including heroin, methadone, hydrocodone (Vicodin®, Norco®), oxymorphone (Opana® ), hydromorphone (Dilaudid® ) and oxycodone (Oxycontin®) have reached epidemic proportions. It can be very difficult to wean off of these drugs. Those addicted to opioids often report they are no longer receiving the benefits of these drugs whether it is euphoria or pain control, and using has become a matter of avoiding withdrawal symptoms.
Although withdrawal from opioids is usually not life threatening--in contrast to withdrawal from alcohol and benzodiazepines--it is often associated with severe discomfort and cravings. It is not uncommon to quickly return to using them.
Because symptoms of opioid withdrawal can be severe, please make sure you are safe when you travel to and from appointments - unless your visits are virtual.
Your personally tailored withdrawal regimen will be explained; side effects and the risk and benefits of the medications, along with what may happen should you choose not to take the medication will also be outlined. If you consent to treatment, medications will be prescribed.
If initiation of buprenorphine is an appropriate part of your withdrawal regimen, a controlled substance consent and agreement form will need to be signed before treatment takes place.
SEDATIVE HYPNOTICS WITHDRAWAL AND TAPER MANAGEMENT
Treatment for sedative and hypnotics addiction such as benzodiazepines pose the same health risks as withdrawal from alcohol because they affect similar receptors (GABA-receptors), therefore discontinuing them abruptly can lead to conditions such as withdrawal seizures and hallucinations requiring emergency hospitalization.
In the elderly and those with a history of alcohol withdrawal seizures, hallucinations, delirium tremens, prior hospitalization for severe withdrawals, or significant cardio-vascular disease should seek inpatient (hospital) care, as the recurrence of a life threatening, complicated withdrawal is high.
Sedative and Hypnotics include tranquilizers and sleeping pills in the barbiturate and benzodiazepine families such as Ambien®, Ativan®, Dalmane®, Klonopin®, Restoril®, Valium®, Xanax®, and others.
The safest most tolerable way to withdrawal from benzodiazepines is to wean off slowly over time. Withdrawal symptoms may include anxiety, insomnia, irritability, and dysphoria. Taper rates vary to the individual. Sometimes post-acute withdrawal symptoms may last months or years.
There are some circumstances in which it is necessary to use a longer acting benzodiazepine substitution and the taper that long acting benzodiazepine over time.
Your personally tailored tapering schedule will be explained to you; side effects and the risk and benefits of the treatment will be explained. If you consent to treatment, medications will be prescribed. For those being slowly tapered off a benzodiazepine, a separate treatment agreement must be signed.
I do not maintain patients on benzodiazepines indefinitely. For patients with co-morbid anxiety disorders, it is important that you also have a psychiatrist, with whom I can work closely. It is preferable that you not be on long term benzodiazepines if you have a substance use disorder, given its high dependency potential, especially for those suffering from alcohol use disorders. However, in a very small number of cases, a low dose, low potency benzodiazepine may be used under joint addiction medicine and psychiatry supervision. However, if at any point your benzodiazepine use begins to interfere with meaningful recovery, this will need to be addressed. If we cannot agree on an intervention, you may need to be referred to another addiction specialist or rehabilitation center that can better meet your needs.
STIMULANT USE DISORDER
Psychoactive stimulants such as cocaine and amphetamines are highly addictive with devastating consequence. However, withdrawal is usually not life threatening unless there are underlying medical conditions. There are some off-label uses of medications for the treatment of stimulant use disorders and their withdrawal. The primary treatment for stimulant withdrawal is providing a safe, supportive environment where you can sleep, hydrate, and be nourished adequately. Contingency management has been shows to be efficacious for stimulant use disorders, however, I do not provide this.
If your stimulant dependence is the result of prescription use for treatment of disorders such as ADHD, it is advisable that you work with your prescribing physician or that I coordinate care with your most recent psychiatrist. It is important to receive a full assessment of ADHD symptoms.
Long-term stimulant use can often result in heart and blood pressure problems. If during your evaluation it is determined that you have cardio-vascular issues needing immediate attention, you may be referred to a cardiologist.
CANNABIS WITHDRAWAL
It was once thought that there was no true withdrawal from cannabis. This has been refuted in recent literature. Anxiety, irritability and insomnia are some of the most common withdrawal symptoms from long term cannabis use. Psychoses (hallucinations and persistent altered perceptions) are also related to cannabis use.
Anti-anxiety medication(s) may be used temporarily to support withdrawal from marijuana. If anxiety becomes severe and persistent, a referral to an addiction psychiatrist will be made and long term treatment with an anti-anxiety medication that is preferably non-addictive may be warranted.
All initial consultation visits, including withdrawal management visits, consist of :
- a comprehensive review of medical and psycho-social history
- physical exam - currently limited due to virtual visits
- laboratory referrals and urine testing is referred out
- treatment planning
- coordination of care
Initial office visits are usually 60-90 minutes long. Follow-ups are 40 minutes.
It is not guaranteed that medications, such as buprenorphine will be prescribed at the first visit without full evaluation and examination of prior prescribing history.
Anticipate that the acute phase of withdrawal process will last up to seven days and it is not unusual to take off from work and have assistance from family and friends during this time.
It is important to rest when in withdrawal (which can be protracted), just as you might after any significant medical procedure. Wanting to be “fixed, better and back to functioning” is a worthy aspiration which will happen; however, rushing the recovery process does not enable lasting integration of recovery skills that help prevent return to harmful or problematic use.
Take the time to mend, if you remain abstinent, you will not have to go through withdrawals again.
ALCOHOL WITHDRAWAL MANAGEMENT
Alcohol withdrawal management may be life threatening and requires close medical monitoring and supervision. The elderly and those with a history of alcohol withdrawal seizures, hallucinations, delirium tremens, prior hospitalization for severe withdrawals, or significant cardio-vascular disease should seek inpatient (hospital) care as the recurrence of a life threatening, complicated withdrawal is high.
However, the majority of individuals wishing to withdrawal from alcohol may be treated on an outpatient basis, in an office setting. The most concerning risk of outpatient alcohol withdrawal medication management is an accidental over-dose with the medications given to treat withdrawal symptoms, especially when mixed with alcohol or opioids during a relapse while attempting to go through a withdrawal process. This situation could be fatal.
For your safety during withdrawal treatment from alcohol, you must provide the contact of a companion (friend or relative) to all of the office visits (in person or virtually) associated with your withdrawal process. This person will be responsible for monitoring your medications and calling the treating physician in the event of any complications, as well as inquiring about any adjustments in the dose of medications.
Your personally tailored withdrawal regimen will be explained to you and your companion; side effects and the risk and benefits of the medications, along with what may happen should you choose not to take the medications will be explained as well. If you consent to treatment, medications will be prescribed.
Patients undergoing alcohol withdrawal treatment will be given a phone number to call for urgent issues related to withdrawals that may be used after office hours until 10 pm. For medical emergencies please call 911 or go to the nearest emergency room.
OPIOID WITHDRAWAL MANAGEMENT
Dependency on opioids including heroin, methadone, hydrocodone (Vicodin®, Norco®), oxymorphone (Opana® ), hydromorphone (Dilaudid® ) and oxycodone (Oxycontin®) have reached epidemic proportions. It can be very difficult to wean off of these drugs. Those addicted to opioids often report they are no longer receiving the benefits of these drugs whether it is euphoria or pain control, and using has become a matter of avoiding withdrawal symptoms.
Although withdrawal from opioids is usually not life threatening--in contrast to withdrawal from alcohol and benzodiazepines--it is often associated with severe discomfort and cravings. It is not uncommon to quickly return to using them.
Because symptoms of opioid withdrawal can be severe, please make sure you are safe when you travel to and from appointments - unless your visits are virtual.
Your personally tailored withdrawal regimen will be explained; side effects and the risk and benefits of the medications, along with what may happen should you choose not to take the medication will also be outlined. If you consent to treatment, medications will be prescribed.
If initiation of buprenorphine is an appropriate part of your withdrawal regimen, a controlled substance consent and agreement form will need to be signed before treatment takes place.
SEDATIVE HYPNOTICS WITHDRAWAL AND TAPER MANAGEMENT
Treatment for sedative and hypnotics addiction such as benzodiazepines pose the same health risks as withdrawal from alcohol because they affect similar receptors (GABA-receptors), therefore discontinuing them abruptly can lead to conditions such as withdrawal seizures and hallucinations requiring emergency hospitalization.
In the elderly and those with a history of alcohol withdrawal seizures, hallucinations, delirium tremens, prior hospitalization for severe withdrawals, or significant cardio-vascular disease should seek inpatient (hospital) care, as the recurrence of a life threatening, complicated withdrawal is high.
Sedative and Hypnotics include tranquilizers and sleeping pills in the barbiturate and benzodiazepine families such as Ambien®, Ativan®, Dalmane®, Klonopin®, Restoril®, Valium®, Xanax®, and others.
The safest most tolerable way to withdrawal from benzodiazepines is to wean off slowly over time. Withdrawal symptoms may include anxiety, insomnia, irritability, and dysphoria. Taper rates vary to the individual. Sometimes post-acute withdrawal symptoms may last months or years.
There are some circumstances in which it is necessary to use a longer acting benzodiazepine substitution and the taper that long acting benzodiazepine over time.
Your personally tailored tapering schedule will be explained to you; side effects and the risk and benefits of the treatment will be explained. If you consent to treatment, medications will be prescribed. For those being slowly tapered off a benzodiazepine, a separate treatment agreement must be signed.
I do not maintain patients on benzodiazepines indefinitely. For patients with co-morbid anxiety disorders, it is important that you also have a psychiatrist, with whom I can work closely. It is preferable that you not be on long term benzodiazepines if you have a substance use disorder, given its high dependency potential, especially for those suffering from alcohol use disorders. However, in a very small number of cases, a low dose, low potency benzodiazepine may be used under joint addiction medicine and psychiatry supervision. However, if at any point your benzodiazepine use begins to interfere with meaningful recovery, this will need to be addressed. If we cannot agree on an intervention, you may need to be referred to another addiction specialist or rehabilitation center that can better meet your needs.
STIMULANT USE DISORDER
Psychoactive stimulants such as cocaine and amphetamines are highly addictive with devastating consequence. However, withdrawal is usually not life threatening unless there are underlying medical conditions. There are some off-label uses of medications for the treatment of stimulant use disorders and their withdrawal. The primary treatment for stimulant withdrawal is providing a safe, supportive environment where you can sleep, hydrate, and be nourished adequately. Contingency management has been shows to be efficacious for stimulant use disorders, however, I do not provide this.
If your stimulant dependence is the result of prescription use for treatment of disorders such as ADHD, it is advisable that you work with your prescribing physician or that I coordinate care with your most recent psychiatrist. It is important to receive a full assessment of ADHD symptoms.
Long-term stimulant use can often result in heart and blood pressure problems. If during your evaluation it is determined that you have cardio-vascular issues needing immediate attention, you may be referred to a cardiologist.
CANNABIS WITHDRAWAL
It was once thought that there was no true withdrawal from cannabis. This has been refuted in recent literature. Anxiety, irritability and insomnia are some of the most common withdrawal symptoms from long term cannabis use. Psychoses (hallucinations and persistent altered perceptions) are also related to cannabis use.
Anti-anxiety medication(s) may be used temporarily to support withdrawal from marijuana. If anxiety becomes severe and persistent, a referral to an addiction psychiatrist will be made and long term treatment with an anti-anxiety medication that is preferably non-addictive may be warranted.
QUITTING SMOKING
© C Y A Chen 2009 Haleiwa
NICOTINE DEPENDENCY AND TREAMENT FOR TOBACCO USE DISORDERS
Nicotine is by far the most addictive drug known, even more addictive than heroin. Tobacco smoking is responsible for almost half a million deaths annually in the United States alone. It is a leading cause of heart and lung disease, and is implicated in many forms of cancer (oral, lung, breast, bladder, cervical, kidney to name a few).
There is now evidence of negative health consequences of third-hand smoke in addition to the damage caused by second-hand smoke. Third-hand smoke is the residual smoke that remains on clothes, the upholstery, and the carpets, which may adversely affect young children and the elderly the most.
Statistically it takes about an average of eight quit attempts to successfully quit smoking. Therefore, the key is to be persistent, trying frequently, along with seeking psycho-social support and coaching on how to modify lifestyle.
In the meantime, there are medications that can assist in the process of nicotine withdrawal and aid in relapse prevention.
Nicotine replacement therapy (NRT) includes, nicotine gums, patches, lozenges, and inhalers.
Buproprion (Zyban®, Wellbutrin®), the only FDA drug approved to thwart cravings has also been shown to be effective especially in combination with NRT.
Varenicline (Chantix®) is highly effective; however, it may produce concerning side effects and may not be the best choice for you. Therefore, a thorough evaluation to see if you are an appropriate candidate for this medication must be made.
It was once thought that when recovering from alcohol and drugs that it was better to allow the recovering person to continue smoking cigarettes because it was stressful enough to stop using drugs and alcohol. However, newer evidence has shown that stopping smoking at the same time may improve relapse rates to alcohol use as well. Therefore, I encourage smoking cessation at the outset of detoxification and recovery.
I have recently worked with my local legislator on a California AB541 (Berman), requiring drug and alcohol treatment centers to screen and offer treatment for tobacco smoking disorder.
Nicotine is by far the most addictive drug known, even more addictive than heroin. Tobacco smoking is responsible for almost half a million deaths annually in the United States alone. It is a leading cause of heart and lung disease, and is implicated in many forms of cancer (oral, lung, breast, bladder, cervical, kidney to name a few).
There is now evidence of negative health consequences of third-hand smoke in addition to the damage caused by second-hand smoke. Third-hand smoke is the residual smoke that remains on clothes, the upholstery, and the carpets, which may adversely affect young children and the elderly the most.
Statistically it takes about an average of eight quit attempts to successfully quit smoking. Therefore, the key is to be persistent, trying frequently, along with seeking psycho-social support and coaching on how to modify lifestyle.
In the meantime, there are medications that can assist in the process of nicotine withdrawal and aid in relapse prevention.
Nicotine replacement therapy (NRT) includes, nicotine gums, patches, lozenges, and inhalers.
Buproprion (Zyban®, Wellbutrin®), the only FDA drug approved to thwart cravings has also been shown to be effective especially in combination with NRT.
Varenicline (Chantix®) is highly effective; however, it may produce concerning side effects and may not be the best choice for you. Therefore, a thorough evaluation to see if you are an appropriate candidate for this medication must be made.
It was once thought that when recovering from alcohol and drugs that it was better to allow the recovering person to continue smoking cigarettes because it was stressful enough to stop using drugs and alcohol. However, newer evidence has shown that stopping smoking at the same time may improve relapse rates to alcohol use as well. Therefore, I encourage smoking cessation at the outset of detoxification and recovery.
I have recently worked with my local legislator on a California AB541 (Berman), requiring drug and alcohol treatment centers to screen and offer treatment for tobacco smoking disorder.
PROCEDURES
BREATHALYZER / URINE DRUG TESTING AND COST
Breathalyzer tests may be performed during an exam during your office visits. If you are being monitored for legal or custody reasons, refusal to take the test results in a positive report for alcohol use. There is no cost for point of care breathalyzer testing. However, I do work with a vendor who monitors clients with Soberlink Testing.
Random urine toxicology is a standard practice in any addiction medicine practice. It is for your safety that we conduct urine tests as many of the medications prescribed have potential serious side effects if taken in combination with non-prescribed drugs or alcohol. Relapse is unfortunately a reality in chemical dependency treatment and it is sometimes difficult for patients to admit that a relapse has occurred. Urine drug testing will ensure that if you have relapsed, it will alert us to conduct a thorough review of current medications. Some patients use urine drug testing as a tool to hold themselves accountable to their recovery and actually welcome the challenge of random testing.
Please be aware it is standard protocol that any refusal of a urine test or tampered test is considered a questionable or “positive” urine result. Repeated questionable or positive (when it should not be) urine tests indicate there is something amiss in your treatment and an opportunity for discussion for possible referral to higher level of care or to another provider.
The cost for urine drug testing is separate from the office visit cost and I will order the test to a local vendor. Usually insurance will cover the cost or a minimal co-pay is required.
LABORATORY TESTING
If you have a primary care physician please bring in any relevant, recent lab results such as basic metabolic panel, cholesterol panel, complete blood count, B12 levels, Vitamin D levels, liver panel (ALT, AST), hepatitis screen (Hepatitis A, B, and C), HIV testing, and STD screening. It would also be good to know if you are up to date on immunizations, and other preventive medicine screening such as pap smears, colonoscopy, mammograms, and blood pressure.
If it has been a while since you have gotten a full physical with routine blood work, some of the above mentioned labs can be ordered and the results reviewed with you. If it appears that you will need a referral to a primary care physician or another specialist we can coordinate your care.
The cost of laboratory testing is separate from office visit fees and the laboratory usually bills one’s insurance company directly.
Breathalyzer tests may be performed during an exam during your office visits. If you are being monitored for legal or custody reasons, refusal to take the test results in a positive report for alcohol use. There is no cost for point of care breathalyzer testing. However, I do work with a vendor who monitors clients with Soberlink Testing.
Random urine toxicology is a standard practice in any addiction medicine practice. It is for your safety that we conduct urine tests as many of the medications prescribed have potential serious side effects if taken in combination with non-prescribed drugs or alcohol. Relapse is unfortunately a reality in chemical dependency treatment and it is sometimes difficult for patients to admit that a relapse has occurred. Urine drug testing will ensure that if you have relapsed, it will alert us to conduct a thorough review of current medications. Some patients use urine drug testing as a tool to hold themselves accountable to their recovery and actually welcome the challenge of random testing.
Please be aware it is standard protocol that any refusal of a urine test or tampered test is considered a questionable or “positive” urine result. Repeated questionable or positive (when it should not be) urine tests indicate there is something amiss in your treatment and an opportunity for discussion for possible referral to higher level of care or to another provider.
The cost for urine drug testing is separate from the office visit cost and I will order the test to a local vendor. Usually insurance will cover the cost or a minimal co-pay is required.
LABORATORY TESTING
If you have a primary care physician please bring in any relevant, recent lab results such as basic metabolic panel, cholesterol panel, complete blood count, B12 levels, Vitamin D levels, liver panel (ALT, AST), hepatitis screen (Hepatitis A, B, and C), HIV testing, and STD screening. It would also be good to know if you are up to date on immunizations, and other preventive medicine screening such as pap smears, colonoscopy, mammograms, and blood pressure.
If it has been a while since you have gotten a full physical with routine blood work, some of the above mentioned labs can be ordered and the results reviewed with you. If it appears that you will need a referral to a primary care physician or another specialist we can coordinate your care.
The cost of laboratory testing is separate from office visit fees and the laboratory usually bills one’s insurance company directly.
PAYMENT POLICY
© C Y A Chen 2010
FEES AND INSURANCE
I am happy to discuss my fees with you during a consultation call. I am also available on retainer for legal consultations.
Because of the sensitive nature of addiction medicine and a wide variance of health care coverage, I do not accept insurance, operating on a fee-for-service basis only.
The following information will assist you in understanding the payment policy for services rendered by my clinic. The responsibility for payment rests with you and is consistent with standard insurance plans.
Payment is due in full at the completion of each appointment once services have been rendered. *Please be aware that I do not accept Medicare or Medi-Cal insurance, therefore please do not submit billing to these entities.
Payment by cash, Visa or Master Card only is accepted.
FILING A CLAIM WITH YOUR INSURANCE COMPANY
We suggest you call your insurance company (the customer service number is usually listed on the back of your insurance card, or go online) and check your benefits prior to your appointment. Please familiarize yourself with your insurance policy and confirm what is covered and what is not. Insurance plans vary and may not cover 100% of your medical costs especially when it applies to behavioral and mental health conditions including substance use disorders.
The signed billing invoice you receive at each visit has the appropriate medical diagnosis and billing codes for you to submit to your insurance company. At the completion of each appointment we will provide you with this signed billing invoice that will have all the medical ICD-10 diagnoses and CPT fee codes. This is the document you submit when you file a claim with the insurance company along with a copy of your medical insurance card (front and back).
Please bring your medical insurance card with you at the time of your initial consultation so that we may keep a copy of it for your record and submit it do the urine drug testing company. We may need to furnish your medical insurance company with additional information regarding services rendered but will do so only with your consent.
Keep in mind that my clinic is not a provider for any medical insurance companies. You are financially responsible for all charges whether or not paid by your insurance.
CANCELLATION POLICY
Missed visits or same day cancellation for appointments will be subject to the cost of the visit; cancellations done last minute create hardship on the
staff, please make cancellations at least 24 hours in advance. We will contact you to confirm your appointment at least 24 hours in advance so that you have an opportunity to cancel in time.
Please direct any questions or concerns regarding billing when you see me.
It is a privilege providing this service for you. Thank you.
I am happy to discuss my fees with you during a consultation call. I am also available on retainer for legal consultations.
Because of the sensitive nature of addiction medicine and a wide variance of health care coverage, I do not accept insurance, operating on a fee-for-service basis only.
The following information will assist you in understanding the payment policy for services rendered by my clinic. The responsibility for payment rests with you and is consistent with standard insurance plans.
Payment is due in full at the completion of each appointment once services have been rendered. *Please be aware that I do not accept Medicare or Medi-Cal insurance, therefore please do not submit billing to these entities.
Payment by cash, Visa or Master Card only is accepted.
FILING A CLAIM WITH YOUR INSURANCE COMPANY
We suggest you call your insurance company (the customer service number is usually listed on the back of your insurance card, or go online) and check your benefits prior to your appointment. Please familiarize yourself with your insurance policy and confirm what is covered and what is not. Insurance plans vary and may not cover 100% of your medical costs especially when it applies to behavioral and mental health conditions including substance use disorders.
The signed billing invoice you receive at each visit has the appropriate medical diagnosis and billing codes for you to submit to your insurance company. At the completion of each appointment we will provide you with this signed billing invoice that will have all the medical ICD-10 diagnoses and CPT fee codes. This is the document you submit when you file a claim with the insurance company along with a copy of your medical insurance card (front and back).
Please bring your medical insurance card with you at the time of your initial consultation so that we may keep a copy of it for your record and submit it do the urine drug testing company. We may need to furnish your medical insurance company with additional information regarding services rendered but will do so only with your consent.
Keep in mind that my clinic is not a provider for any medical insurance companies. You are financially responsible for all charges whether or not paid by your insurance.
CANCELLATION POLICY
Missed visits or same day cancellation for appointments will be subject to the cost of the visit; cancellations done last minute create hardship on the
staff, please make cancellations at least 24 hours in advance. We will contact you to confirm your appointment at least 24 hours in advance so that you have an opportunity to cancel in time.
Please direct any questions or concerns regarding billing when you see me.
It is a privilege providing this service for you. Thank you.
Copyright © Chwen-Yuen Angie Chen, MD 2013-2023. All Rights Reserved.