Are Treatments Covered
by Insurance?  

Financial Agreement for Ketamine Infusion Services 

 

This Financial Agreement is made on ________________(Today’s Date), by and between _________________________________(“Patient”) and TMHCare, PC ("Provider"). 

 

Payment Terms 

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Option 1: Insurance Billing

1. Membership Fee: $250 per session, paid at the time of treatment.

2. Insurance Billing: Provider will submit claims to the Patient's insurance for the appropriate CPT codes.

3. Services Billed to Insurance:

   1. ​Ketamine Infusion (96365): $125

   2. Office Visit (99215): $400

   3. Monitoring (99417 x4): $375 (+ $100 for each additional hour beyond a 1-hour infusion)

 

Important Notes:

1. Insurance coverage for ketamine treatments is not guaranteed, as ketamine is FDA-approved only for anesthesia purposes.

2. The Patient is responsible for any copays, coinsurance, and deductibles.

 

Option 2: Self-Pay (No Insurance Billing)

1. Self-Pay Agreement: By selecting this option, the Patient agrees not to seek reimbursement from their insurance and will not receive superbills for the treatments.

2. Membership Fee: $250 per session, payable at the time of treatment.

3. Treatment Cost: $200, payable upfront.

4. Total Due at Time of Treatment: $450
    

Agreement Details 

1. Provider’s Responsibilities

   1. ​Submit claims to the Patient’s insurance promptly. 

2. Patient’s Responsibilities 

   1. Due Diligence: The Patient agrees to verify their insurance eligibility and coverage for the desired services prior to all scheduled appointments. Patients are strongly encouraged to contact their insurance provider to inquire about specific out-of-pocket costs, including copays, coinsurance, and deductible amounts, to ensure they fully understand the financial responsibility for the services provided.

   2. Provide Accurate Insurance Information: Ensure my insurance details are up to date. 

   3. Make Upfront Payment: Pay the $250 membership before treatment if we are billing out to insurance or pay the $250 membership fee as well as $200 for the treatment ($450 in total) if we are not billing out to insurance.

3. No Refunds Policy

4. Membership Fee & Upfront Payments: As part of our updated membership fee structure, the $250 membership fee is non-refundable once paid. This fee covers premium services and non-insurance-billable services, and will be charged at the time of each session.

5. Insurance Billing: Once your insurance claim has been processed and paid, the membership fee and treatment costs are considered final, and no refunds will be issued for any payments made, including those for services covered by insurance.

6. Self-Pay Patients: For patients choosing the self-pay option, the total upfront cost of $450, including the membership fee and treatment, is non-refundable once paid.

 

Credit Card Authorization

1. The Patient authorizes the Provider to keep their credit card on file for future transactions related to medical services.

2. The Patient agrees that the card may be charged for outstanding balances and will receive prior notification of any charges.

3. This authorization remains in effect until written notice of cancellation is provided.

 

Dispute Resolution 

1. Any disputes arising from this Agreement will be resolved through mediation, arbitration, or small claims court, as agreed upon by both parties. 

 

Acknowledgment & Acceptance 

1. By signing this Agreement, the Patient acknowledges and agrees to the terms and conditions stated herein. 

 

Signature: ______________________________________ 

Date: __________________________________________