I. PAYMENT

By my signature below, I understand, acknowledge, and agree that I am fully responsible for payment of services provided to me by Evansville Ketamine and that payment must be made in full by cash or credit card at or before the time of service.

I understand that treatment and services provided by Evansville Ketamine may not be covered by my insurance. Evansville Ketamine and its physicians are non-participating providers and do not contract with any insurance plan, medicare, or medicaid. Evansville Ketamine will provide information to me to assist me in my claim for reimbursement to my insurance carrier, but will not submit claims to insurers on my behalf and is not required to speak with insurance companies on my behalf. I understand I have the right to explore with medicare, medicaid or other insurance companies whether outpatient or inpatient ketamine infusion is a covered benefit under my plan and to find another practice that may contract with medicare, medicaid or other insurance companies.

I further acknowledge and agree that if I choose to submit any bill or itemized receipt to an insurance carrier for reimbursement for these services, that Evansville Ketamine is exempt from any dispute regarding reimbursement.

II. CANCELLATION

To fairly and effectively serve patients who wish to receive treatment, the following cancellation policy has been implemented. By your signature below you acknowledge and agree to the following cancellation policy:

Infusions for psychiatric disorders must be cancelled at least 72 business hours in advance. 40 minute infusions cancelled at least 72 business hours in advance will receive a full refund. 40 minute infusions cancelled less than 72 business hours in advance will incur a $150 charge, payable by funds pre-paid to your account or charged to your credit card on file. Our business hours are Monday through Friday.

Infusions for pain conditions must be cancelled at least two weeks in advance. Infusions cancelled at least two weeks in advance will receive a full refund. Two to four hour Infusions cancelled less than two weeks in advance will incur a $350 charge, payable by funds pre-paid to your account or charged to your credit card on file.