410-848-4424

Forms & Policies

Office & Financial Policies

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Financial Policy

Fill out this form, print and bring with you to your initial visit.

Forms Per Family

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Patient & Family Demographic Form

Fill out this form, print and bring with you to your initial visit.

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Vaccine Policy

Fill out this form, print and bring with you to your initial visit.

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Consent to Treat Form

Fill out this form, print and bring with you to your initial visit.

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Financial Policy

Fill out this form, print and bring with you to your initial visit.

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Divorced and Separated Parents Form

Print and sign this form and bring with you to your initial visit.
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Consent to Contact

Print and sign this form and bring with you to your initial visit.

Forms Per Patient

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Prescription Refill Request Form

Print and fill out this form and fax it to
410-876-5330.
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HIPAA

Print and sign this form and bring with you to your initial visit.

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Family Medical Health History

Fill out this form, print and bring with you to your initial visit.
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Records Release

Authorization for Release of Medical Information.  Print and sign this form and bring with you to your initial visit.

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VFC Eligibility Screen

Print and sign this form and bring with you to your initial visit.

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Preventative Exam Billing Notice

Preventative Exam Billing Notice.  Print and sign this form and bring with you to your visit.

Our Location

230 Washington Heights
Medical Center
Westminster, MD 21157
410-848-4424

Hours

Our office is open:

Effective Oct 18, 2022

  • Mon - Thurs 8am - 5pm
  • Friday 8am - 4pm

Insurance Accepted

  • Aetna
  • Assurant Health
  • Carefirst
  • Cigna
  • Coresource
  • Maryland Medical Assistance
  • MD Physicians Care
  • MDIPA
  • OneNet
  • PHCS
  • Priority Partners
  • UHC-Americhoice
  • UMR
  • United Health Care
  • And more....