Patient Forms

Patient Forms

Office Policies

Financial Information + Fees

Insurance: We are in network with Maryland Medicaid, Medicare, and Tricare and most commercial insurances including CareFirst, Cigna, United Healthcare, and Aetna. Services may be covered in full in part by your health insurance or employee benefit plan. Please check your coverage carefully.

Self-pay rates: for initial evaluation (including psychiatric and medications for substance use disorder) the cost is $255 and for follow up appointments $150. For psychotherapy and pain reprocessing sessions the cost is $180.

Letters, forms, record reviews, and interactions with outside agencies requiring significant attention outside of scheduled appointment times will be filled out at the provider's discretion. Any form that requires a considerable amount of time will not be completed on the same day and will be subject to a fee of $75 per hour. Please allow 48 to 72 business hours for completion. This excludes activities deemed by the provider to be clinically essential, such as interacting with other clinicians directly involved in your care and executing routine duties such as providing refills, performing authorization requests for medications or certain treatments, and brief clinically-focused return of patient phone calls.

It is your responsibility as a patient to provide accurate and current information at the time of service so that your insurance company can be billed. Financial responsibility rests with the patient for deductibles, co-insurance, and non-covered services. Co pays and account balances are due at the time of service. We accept Visa, Mastercard, American Express, Discover, cash, personal check, Google, CashApp, Venmo, and virtual credit cards are accepted. 

Cancellations, Rescheduling + No-Shows

Please provide us with at least 24 hours notice of appointment cancellations or rescheduling. This allows us to offer your spot to someone on the waitlist. All no-shows will be billed as full office visits. Although consideration can sometimes be given to circumstances truly beyond your control, we ask to you let us know as soon as possible. More than two cancellations and no shows will result in cancellation and discharge of further services. We will make attempts to reschedule your appointments based on your provider’s availability and comfort with your plan of care. 

Late Appointments

If our appointment begins late because you arrived late, the session will end at the time it normally would have ended. This is so that other patients may stay on schedule. If we begin late because the providers are behind schedule, the session will be of its normal duration, to assure that patient concerns receive full and proper attention.

If you arrive after the scheduled session has ended, we can sometimes accommodate you, if an already scheduled appointment cancels or no-shows, but this cannot be guaranteed. Otherwise, the visit will count as a no-show.

Emergency Appointments

At your provider’s discretion we will make every effort to accommodate crisis situations and the need for earlier appointments. However, you may need to check with us daily for cancellations if no appointments are available immediately. Likewise, we cannot guarantee immediate rescheduling of missed appointments.

Discharge + Termination of Patient Relationship

Treatment non-adherence: The client does not or will not follow the treatment plan any of the terms of the substance-controlled contract or discontinues medication or therapy regimens prior to completion.

• Follow-up noncompliance: The client repeatedly cancels follow-up visits or fails to keep scheduled appointments with providers or consultants.

• Office policy nonadherence: The client fails to observe office policies, such as those implemented for prescription refills or appointment cancellations or refuses to adhere to mandated infection-control precautions.

• Verbal abuse or violence: The client, a family member, or a third-party caregiver is rude, uses disparaging or demeaning language, or sexually harasses office personnel or other patients, visitors, or vendors; exhibits violent or irrational behavior; makes threats of physical harm; or uses anger to jeopardize the safety and well-being of anyone present in the office.

• Display of firearms or weapons: The client, a family member, or a third-party caregiver wields a firearm or weapon on the premises.

• Inappropriate or criminal conduct: The client exhibits inappropriate sexual behavior toward providers or staff or participates in drug diversion, theft, or other criminal conduct involving the practice.

• Nonpayment: The client owes a backlog of bills and has declined to work with the office to establish a payment plan or has discontinued making payments that had been agreed on previously.

Innovative Treatment Centers, LLC will provide a formal written notice stating withdrawal of care based on the conditions mentioned above and requiring patient to find another practitioner. The written notice will be via email, first class and certified receipt requested. Innovative Treatment Centers, LLC will make every attempt to provide care for up to 30 days of the notice or until the client is able to see another provider, whichever is sooner. 

Referrals + Services Provided for Reasonable Accommodation + Leave

Some health insurance companies may require a referral for your visit to our office. Please make sure to contact your insurance company and/or your primary care physician to ensure that you do get a referral if it is required. Failure to obtain a referral, when necessary, may cause your insurance company to deny your claim. Letters requesting accommodation and leave of absence from work or school will require an established relationship between the provider and client. Requests for such services will not be provided on the first visit and the length of the established patient-client relation will be subject to the provider’s discretion. Letters, forms, record reviews, and interactions with outside agencies requiring significant attention outside of scheduled appointment times, will be subject to a fee of $75 per half-hour. This excludes activities deemed by the provider to be clinically essential, such as interacting with other clinicians directly involved in your care, and executing routing duties such as providing refills, filling out routine authorizations requests, and brief clinically-focused return of patient phone calls.

Prescription Refills

Refill of controlled substances is subject to the provider’s discretion and adherence to controlled substance contract. Ideally most controlled substances will require an appointment to ascertain the need for services. We prefer to refill your medications at the time of your office visit. Please bring your medication list with you to each appointment. Please be sure to give us at least 48 hours’ notice on all refill requests. Chronic or long-term medication refills require an office visit before they may be refilled. In other cases, we request that you contact your pharmacy for medication refills. The pharmacy will fax a request to our office with all pertinent information. 

Medical Records

A Release of Medical Records must be signed to have your patient records sent to another health care provider. If you request that your records, be sent to another provider, we ask that you supply us with their name, address, and phone number.