APPOINTMENT NO-SHOW POLICYBeginning April 15, 2025 APPOINTMENT NO-SHOW POLICY BEGINNING April 15, 2025 Dear NPME Patient/Caregiver: We understand that your appointment may need to be canceled or rescheduled occasionally. In such circumstances, please contact us no later than 24 hours before your appointment. You may do so by emailing us at appt@northernpharmacy.com or calling 410-254-2056 x258. If you do not cancel or reschedule your appointment within 24 hours of your appointment time, we will consider that a no-show. No-show appointments will be subject to a $45 fee. No-show fees are the patient’s sole responsibility and will be charged to the credit card you put on file to use for this event. By giving us the credit card to put on file for the No-Show fee, you are agreeing to the charge on the card if you do not properly cancel or reschedule your appointment, more than 24 hours in advance of your scheduled appointment. We know that unexpected situations sometimes arise. In the case of emergencies or extenuating circumstances, we may waive the no-show fee. Waivers are determined on a case-by-case basis at management's sole discretion. If Northern Pharmacy and Medical Equipment must cancel your appointment with less than 24 hours’ notice, you may choose to meet with a different provider (if available) on the same day, reschedule, or to cancel. In these circumstances, we will not charge you a cancellation fee. If you have questions about our cancellation policy, or you’re experiencing an emergency, please email us at appt@northernpharmacy.com. Thank you. Your NPME Specialist Patient Acknowledgment and Consent Form Appointment No Show/Cancelation: I, the undersigned, acknowledge that I have read and if asked received a copy of the Northern Pharmacy and Medical Equipment Appointment Cancelation/No Show Policy. I fully understand that I must give Twenty-Four (24) hour’s notice via email or by phone to cancel and/or reschedule my appointment or I will be charged a $45 No-Show Fee. This fee will be charged to the Credit Card I gave to Northern Pharmacy and Medical Equipment to hold on file for such an event. By checking the box below, I agree that my printed name shall serve as my legal signature, affirming my acknowledgment and consent. I agree to the use of my printed name as my signature and confirm that I have received the Medicare Quality Standards. * I Agree Printed Name: * Date of Birth: * MM DD YYYY Date Signed: * MM DD YYYY Thank you! Medicare Supplier Standards
