Late Cancellation/No Show Waiver Request - LCOHPA Late Cancellation/No Show Waiver Request _LCOHPA "*" indicates required fields Patient Name:* First Last Phone:*Patient DOB: MM slash DD slash YYYY Clinician Name: I am requesting a waiver of the No Show/Cancellation Fee that was applied to the above date of service for the following reason:1. I called the scheduling number 513-536-0570 greater than 24 hours before my appointment. Phone Number from which I called:*Date Called:* MM slash DD slash YYYY Time Called:* Hours : Minutes AM PM AM/PM 2. The cancellation or no show is caused by death of a family member Name of the Deceased:* Relationship to the Deceased:* Funeral Home/Mortuary Name:* Funeral Home Phone Number:*Other documentation:3. I was receiving treatment in a hospital, emergency room, or urgent care facility. Name of Hospital or Medical Facility*Date of admission:* MM slash DD slash YYYY Date of discharge* MM slash DD slash YYYY By my signature below, I certify that everything I have stated on this application is true.Signature (patient/applicant):*Date MM slash DD slash YYYY HiddenSection BreakHiddenOffice Use Only: Applicant notified of approval or denial on Date: HiddenMRN# HiddenHow Notified? HiddenStaff Member: HiddenCharge removed in Epic on HiddenCharge removed in IDX on CAPTCHA