ACKNOWLEDGMENT OF PAYMENT & CANCELLATION POLICY

I. Payment

By my signature below, I understand, acknowledge, and agree that I am fully responsible for payment of services provided to me by Vitalitas Denver, PC and that payment must be made in full at or before the time of service.  The cost of a 40-minute infusion is $375, a 2-hour infusion is $700, a 3-hour infusion is $975, and a 4-hour infusion is $1,350.

I understand that treatment and services provided by Vitalitas Denver may not be covered by my insurance.  Vitalitas Denver and its physicians are non-participating providers and do not contract with any insurance plan.  Vitalitas Denver 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.  We are also unable to fill out paperwork for insurance companies.  I understand I have the right to explore with medicare, medicaid or other insurance companies whether outpatient or inpatient ketamine intravenous infusion is a covered benefit under my plan and to find another practice that may contract with medicare, medicaid or other insurance companies.

I acknowledge that if I have medicaid/Health First Colorado, it does not cover ketamine intravenous infusions given by a doctor in the outpatient setting for chronic pain or mental health.  I am entering into a private agreement with Vitalitas Denver, PC to pay for my infusions.  Because I will be getting repeat infusions in this practice, this agreement covers all future infusions as well.  By signing below I further acknowledge that I am financially responsible for the full cost of the services.

I acknowledge and agree that if my insurance changes to medicare or medicaid, it is my responsibility to notify Vitalitas Denver PC in writing before my next scheduled appointment, so the proper paperwork can be filled out.  Vitalitas Denver, PC has chosen to opt out of medicare and any treatment with Vitalitas Denver, PC is a private contract between myself and Vitalitas Denver, PC and medicare will not be billed by either party.

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 Vitalitas Denver, PC 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:

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

Two to four hour infusions 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 $500 charge, payable by funds prepaid to your account or charged to your credit card on file.

Appointments with Shantel Gallegos, PNP must be cancelled 24 hours in advance.  Appointments not cancelled at least 24 hours in advance will incur a $50 missed visit fee, payable by funds prepaid to your account or charged to your credit card on file.