No Show Fee Appeal Form

No Show Fee Appeal

If you feel there are significant circumstances related to you missing your appointment or your late cancellation, you may submit an appeal request for your No-Show fee.  Please complete and submit the appeal form below.  You have 30 days from the date of your no-show appointment to submit the appeal request.

Please explain your reasons for requesting an appeal of the No-Show fee. If you would like to submit supporting documentation, call the Student Health Services Front Desk (703-993-2831) for instructions. Allow 5 business days after submission for review of your appeal request.  Student Health Services may request supporting documentation.

You will receive an email to your Mason email account informing you of the appeal decision.

No Show Fee Appeal Form

"*" indicates required fields

Student Name*
Responses will only be sent to a Mason email address
Date of the missed appointment*
Please explain your reasons for your appeal of the No Show fee.