Patient Financial Policy

Patient Financial Policy

To reduce confusion and misunderstanding between our patients and practice, we have adopted the following financial policies. If you have any questions regarding these policies, please ask an associate prior to starting your treatment. We have committed to provide the best possible care and service to you. We recognize that informing you and having you gain an understanding of your financial responsibilities is an essential element of your plan of care.

Payment for Services – payment will be collected in full at the time of service.  Acceptable methods of payment are cash, money order, cashier’s check, credit or debit card. Personal checks are currently NOT accepted.

Reimbursement by Insurance/Third-Party Payors – currently Ketamine infusions are not covered by most payors. Ketamine Wellness Center will make no attempt to collect payment from insurance or other third parties; including but not limited to – Centers for Medicare, Veteran Benefits, Medicaid, Private Insurances.

No Show and Cancellation Policy – we require a 24 hour notice if you are unable to keep a previously scheduled appointment.  In the event you do not provide a 24 hour notice or do not show up for your appointment, we reserve the right to charge a $50 fee.

Repetitive No Show and Cancellation Policy – after (3) missed appointments/cancellations with out 24 hours of notice, payment must be made in full prior to scheduling any additional appointments. The full cost of the infusion will be collected at the time of scheduling. No refunds will be given.

End of year statements – at the request of the patient, an itemized statement including dates of service and amounts paid can be created for tax purposes. Please call 920-202-3466 to request an end of year statement.


Financial Policy

I have read and understand the Informed Consent for Ketamine Infusion

Signature Section