Ketamine Treatments - Good Faith Estimate

Patient Name

First NameMiddle NameLast Name

Patient Date of Birth

MonthDayYear

Patient Address

Street Address

Street Address Line 2

CityState

Zip Code

Patient Email

example@example.com

Patient Phone Number

Area CodePhone Number

Do you believe you are eligible for a discounted rate?

YesNoUnsure

Note: Your answer to the question above will not affect the calculation of your estimate. We will note it and if you believe you're eligible, Dr. Charfen will discuss with you in your initial consultation.

Patient Services

Primary Service Requested/Scheduled

Expected Start Date Of Treatment

Date

Expected Treatment/Services*

Initial Assessment/Consultation$200.00

Initial Intake Assessment and Consultation to Evaluate Appropriateness for Ketamine (This is required for all ketamine treatments. If you have Medicare or HMSA insurance, the consultation fee will be submitted for reimbursement.)

Treatment Sessions$395.00

3-Hour Ketamine Session(s) Fee for infusion administration includes the pre-treatment preparation and post-treatment integration.

Administration Method	Anticipated Number of Sessions	Price
Oral or Sublingual		$395.00
IM (intramuscular) or SC (subcutaneous)		$495.00
IV (intravenous)		$695.00

Subtotal $0.00Tax $0.00Total $0.00

Please Note:

This estimate is not a contract and does not obligate you to obtain any services from Dr. Charfen, nor does it include any services rendered to you that are not identified here.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need a specified number of visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to, in consultation with your provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

When you click the "Create Estimate" button below, a document will be created for you in PDF version, which you can download for your reference.

Good Faith Estimate - Ketamine Treatment