We are committed to providing safe, efficient, and transparent care. Please review our updated office policies:

1. Lab & Procedure Results

• Abnormal results: You will be contacted by phone.

• Normal results: Reviewed at your next scheduled visit.

• Please allow 3–5 business days for results.

2. Prescription Refills

• Routine refills can be called in or faxed to your pharmacy; allow up to 72 hours.

• Refill requests should be made at least 5 days before running out.

• Some meds require prior authorization—this may take several days.

• Controlled substances must be electronically sent to your pharmacy.

• Refill faxes: 410-744-8036

3. Labs & Imaging Before Appointments

• Complete all tests ordered at least 5 days before your next visit to ensure timely review.

4. Cancellations / No-Shows

• Less than 24-hour notice or missed appointments: $75 fee (not insurance-covered).

• No-show fees must be paid before your next visit.

• Repeated no-shows may lead to dismissal.

• Weather-related cancellations are exempt—check our Facebook page or call us.

5. Insurance Verification

• We verify insurance before each visit and provide info on your coverage, copay, and deductible.

6. Deductibles & Financial Responsibility

• Payment is due at time of service if a deductible remains: - $650 for new patients - $300 for return visits

• Or your remaining deductible—whichever is less.

• HSA/HRA plan holders may be exempt.

• You may still receive a bill for remaining balances after insurance processing.

7. Copayments

• Copays are required at check-in.

• Accepted payments: credit/debit, HSA cards, or cash.

8. Referrals

• If your plan requires a referral, you must obtain it prior to your visit.

• Without a valid referral: - You may be rescheduled, or - You may be responsible for full cost.

• Bring your insurance card and photo ID to all appointments.

9. Medications & Durable Medical Equipment (DME)

• Insurance benefits are verified before supplying injectable meds or braces.

• If required, meds may be sent to your pharmacy. Otherwise, they are dispensed and billed through our office.

• Braces are dispensed in-office unless your plan specifies otherwise.

10. Billing & Payments

• Claims are submitted to your insurance after each visit.

• Any remaining balance is billed to you—due within 30 days.

• Unpaid accounts after 90 days may be sent to collections per Maryland law.

• Returned checks: $25 fee

11. After-Hours & Weekend Calls

• Non-urgent calls or refill requests after hours may incur a $50 fee.

• Emergencies: Call 911 or go to the nearest ER.

12. Inclement Weather

• Your safety is our priority.

• Weather-related cancellations will not be penalized.

• Check Facebook or call for closure updates.

13. Privacy & HIPAA

• We follow all HIPAA regulations.

• Please update us if your address, phone, or communication preferences change.

14. Patient Choice of Provider & Pharmacy

I, declare the following:

A. A pharmacy is not conveniently available to the patient

B. The determination that a pharmacy is not conveniently available to the patient was made solely by the patient

C. I acknowledge that I have been informed of the option to obtain my prescription drugs from a pharmacy

D. I consent to receive prescription drugs dispensed directly by the licensee.

You have the right to choose your provider and where to fill prescriptions. This includes our new in-office pharmacy, available for your convenience. If your current pharmacy is no longer ideal, speak with your provider about options.

Your rights under Medicare, Medicaid, Tricare, and commercial plans include:

• Freedom to Choose any licensed pharmacy.

• Transparency around medication costs and delivery options.

We offer our in-office dispensary to make your treatment more convenient—but the choice is always yours.

have read and acknowledge receipt of the policies listed above.

Please read before signing MEDICARE: I authorize any holder of medical or other information about me to be released to the Social Security Administration and or its intermediaries or carriers with any information needed for this or related Medicare claim Title (XVII). I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or the party who accepts assignment below. I understand that I am responsible for any health insurance deductible, co-insurance (copay), and non-covered charges.

BLUE SHIELD OF MARYLAND: I understand the charges of a non-participating physician may exceed the Blue Shield of Maryland, Inc payment and, if greater, I will be responsible for that amount. I authorize release of any medical information necessary to process this claim. For charges of a participating provider, I understand that I am responsible for any health insurance deductible, co-insurance (co-pay), and non-covered charges.

LEGAL ASSIGNMENT (applicable to Physician Services): The undersigned expressly agrees if, upon default, this matter is referred for collection, the undersigned agrees to pay for attorney fees of (15%) of the outstanding balance at the time of referral, which percentage and the amount of resulting therefore are considered reasonable by the undersigned, and all court costs incurred therewith, as well as private process server fees.

WORKMAN’S COMPENSATION: I understand that if for any reason my worker’s compensation carrier denies payment for services that were rendered to myself, I will be financially responsible.

AUTOMOBILE INSURANCE: I understand that once my PIP has been exhausted, I will be financially responsible for any charges incurred in the event our office does not accept my health insurance and services that are not authorized by my health insurance.

INSURANCE: I authorize and assign payment directly to the physician involved in my treatment and authorize the release of medical information necessary to process the claim. I further understand I am financially responsible for charges not covered by my insurance.

MANAGED CARE: I understand that without an authorization/referral from my HMO/PPO/PPA/POS plan, I will be financially responsible for charges I incur.

In accordance with federal government privacy rules implemented through the Health Insurance Portability and Accountability Act of 1996 (HIPAA), in order for your physician or his/her staff to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode, or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived.

Please check all that apply:

I grant permission to a representative of JW Infusion Center to do the following:

Leave a message on my answering machine/voicemail or with anyone in my household who answers the telephone. If you do not want us to leave messages for you, please check “NO.” A “YES” indicates your consent.

acknowledge the following:

JW Infusion Center provides the service of enrolling our patients into available copay programs that are provided by drug manufacturers. If approved, we submit explanation of benefits (EOB) to the programs on the patients’ behalf. However, maintaining an active status in these programs is ultimately the responsibility of the patient. Patients must verify their dates of eligibility in the copay assistance program and notify JW Infusion Center when they need to re-enroll. Patients are responsible for monitoring their awarded dollar amount to know if/when they run out of funds and are also responsible for notifying JW Infusion Center when they have exhausted their funds. If a co-pay program does not pay for a claim for any reason, JW Infusion Center will assist the patient in the appeal process. However, if the services are not covered, it is the responsibility of the patient to pay for all non-covered services.