No Show/Late Cancel Fee Appeal Form

University Health Services wants to increase students’ access to service. When a student fails to keep an appointment or cancels at the last minute, professional time goes unused and other students fail to receive timely service.

We understand that on rare occasions there may be extenuating circumstances that prevent you from calling. If we have made an error in scheduling you or you believe you deserve special consideration for a no-show/late cancel fee, please complete and submit the following form, along with any supporting documentation. Your request will be reviewed and you will receive a decision.

Completed forms must be received by UHS no later than 2 weeks from the date of the missed appointment.

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Date of the missed or late-cancelled appointment
MM slash DD slash YYYY
Time of the missed or late-cancelled appointment

: Hours

Minutes

AM/PM
Name of the provider you were scheduled to see
Describe the reason for requesting special consideration
Attach any supporting documentation to this form
Max. file size: 128 MB.

Submit a paper copy

Students may elect to fill out a paper copy of the form (pdf) and deliver it in person or mail it to:

University Health Services
Budget & Finance Office
333 E. Campus Mall
Room 8104
Madison, WI 53715