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1. Patients will get a phone call with all abnormal labs and Procedures. All normal lab results will be discussed at the next office visit.

2. Refills of routine prescriptions can be called in or faxed to your pharmacy. Many prescriptions require prior authorization by your insurance plan, and this may take several days to obtain. Certain pain medications Cannot be called in; We will mail these prescriptions to you or you can pick them up. Please plan ahead and call 4 days before running out of your medications. We make every effort to call in or fax the prescriptions in as soon as possible, but we do ask that you allow 48 hours turnaround time for prescriptions to be sent to the pharmacy. Pharmacies can fax refill requests to 410-744-8036.

3. Laboratory and Radiology requested by the Physician at the previous visit should be done at least 5 days prior to your appointment to assure we receive the results on a timely manner.

4. Cancellation/ Missed visit policy: Please note that as of March 1, 2010, if you miss your appointment without giving at least 24 hours of notice, you will be charged a fee of $75.00 (This fee will not be covered by your health insurance plan). Continuous no shows may result in discharge from our practice.

5. Prior to your appointment, the office will contact your insurance company to verify that your insurance is active and will cover your appointment with our office. We will collect information on your deductible, coinsurance and copayment, if applicable.

6. It is our office policy to collect the office visit fee at the time of service if you have a deductible amount remaining. You will be asked to pay $300 for a new patient visit ($150 for a return visit) or the remaining of your deductible, whichever is lower. If you have an HSA or HRA, then this policy will not apply to you. Please note if you have a high deductible, your total charges may be more than the amount collected at the time of service and you will receive a bill.

7. Copayment will be collected at time of service, prior to seeing the doctor, with no exception. This is part of our contracts with the insurance companies. Please be sure to bring a form of payment.

8. If your insurance company requires referrals, it is your responsibility to bring this referral to your visit and make certain that it is valid every time you make an appointment. It is your responsibility to make certain we have your referral. If you do not have a valid referral for your visit and it is denied by your insurance company, you will be responsible for the full amount of the office visit. If you arrive without the proper referral you will be asked to reschedule your appointment or be financially responsible for the visit if you are seen. Please bring your insurance card and photo ID to each visit.

9. Benefits for braces, infusible and injectable medications will be checked prior to dispensing. For the medications, if it is more cost effective for you, we will send these medications to your pharmacy to have them delivered to our office for administration. Otherwise, the medication will be supplied by our office and all office billing policies will apply. Braces will be dispensed by our office unless otherwise noted by your insurance company.

10. Benefits for braces, infusible and injectable medications will be checked prior to dispensing. For the medications, if it is more cost effective for you, we will send these medications to your pharmacy to have them delivered to our office for administration. Otherwise, the medication will be supplied by our office and all office billing policies will apply. Braces will be dispensed by our office unless otherwise noted by your insurance company.

11. After your visit, we will submit a claim to your insurance company. Once we have received payment and explanation of benefits, any remaining balance up to the allowed amount will be your responsibility. At this time a statement will be generated and mailed to you. The full amount must be paid within thirty days, unless you have contacted our office and made payment arrangement. If no payment or arrangement for payment has been made within 90 days the balance will be sent to a collection agency.

12. If you call your doctor on the weekend or evenings for non-urgent matters you may be charged a $50.00 fee.

13. In case of inclement weather we will try our best to notify you of any closures or delays as far in advanced as possible. However, you are responsible to call and verify that the office is open before your appointment. We value the safety of our patients and employees. You can also check The Nasseri Clinic Facebook page for up to date inclement weather closures and delays. (You will not be charged a no show fee due to inclement weather)

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 dispensary available for your convenience. If your current pharmacy is no longer ideal, discuss the options with your healthcare provider.

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

D. Freedom to Choose any licensed pharmacy.

E. Transparency around medication costs and delivery options.

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

I have read and acknowledge receipt of the policies listed above.

I acknowledge that I have received the Notice of Privacy Practices for Nasseri Clinic of Arthritic and Rheumatic Diseases (NCARD). I understand that NCARD has the right to change its Notice of Privacy Practices from time to time and that I may contact NCARD at any time to obtain a current copy of the Notice of Privacy Practices.

People to whom NCARD may release Patient Care or Billing Information:

*** This release only expires by written request ***

700 Geipe Road • Suite 200 •Catonsville, MD 21228

203 Hospital Drive • Suite 300 • Glen Burnie, MD 21061

3333 North Calvert Street • Suite 540 • Baltimore, MD 21218

9114 Philadelphia Road • Suite 208• Rosedale, MD 21237

5500 Knoll North Dr • Suite 250 • Columbia, MD 21045

724 Maiden Choice Lane, Suite 204, Catonsville, MD 21228

Phone: 410-744-0661 • Fax: 410-744-8036

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 (co-pay), 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 any 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 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 incurred from our clinic.