Carolina Outreach 3012 Falstaff Rd

Raleigh, NC 27610-1813
Medication Management No-Show Policy Agreement 919-615-1027 tel
919-615-1028 fax

Elizabeth S Barajas Client ID: 47794 Born Jul 5, 1978, Medical record no: 459912
female Insurance: IPRS
White or Caucasian Insurance no: 459912

For Basic Services, if a client does not show for 2 medication management appointments or cancels within 24 hours of the appointment
twice within a period of 6 months, the client will be marked as walk-in only. The client may not be scheduled for a follow-up appointment for
a period of 6 months but may be seen in our walk-in clinic for refills and other concerns. If clients who are walk-in only are seen twice in a 6
month period, they will be taken off of the walk-in only restriction and can be scheduled for a follow-up appointment with their provider. If
clients who are walk-in only are not seen at least twice for 6 months in the walk-in clinic, they will be discharged from medication
management at Carolina Outreach.

For Enhanced Services, if a client does not show for 3 medication management appointments or cancels within 24 hours of the
appointment twice within a period of 6 months, the client will be marked as walk-in only. The client may not be scheduled for a follow-up
appointment for a period of 6 months but may be seen in our walk-in clinic for refills and other concerns. If clients who are walk-in only are
seen twice in a 6 month period, they will be taken off of the walk-in only restriction and can be scheduled for a follow-up appointment with
their provider. If clients who are walk-in only are not seen at least twice for 6 months in the walk-in clinic, they will be discharged from
medication management at Carolina Outreach.

To attend the medication management walk-in clinic, the client must call or come into the clinic between 8am and 12pm Monday-Friday
and ask to be added to the walk-in list. When a provider is available to see them, they will be notified by the medical assistant with a phone
call (if virtual) or by taking them to an exam room if in person. If no provider is available to see them in the walk-in clinic that day, they may
try again the following day. If the medical assistant has called the client twice when a provider is available and been unable to reach the
client, the client will then need to call back to be able to be seen by a provider when available.

By signing, you agree to the above policy.