No Show/Late Cancel Appeal Form

• The appeal process can take up to 30 business days before a decision is made.
• There is no guarantee that the appeal process will result in a reversal of the $25.00 No Show/Late Cancel Fee.
• Appeals must be submitted within 30 days of the scheduled appointment to be considered.
• Please print this form and either fax to (765) 496-1907 or drop off in the immunization box on the front of the PUSH building.