Office Policies

• Payment (including co-payment or payment towards deductible) is expected at the time of service.
• No-show & late cancellation fees must be paid prior to your next appointment, or your appointment will be canceled until payment is received.
• Accepted forms of payment: Cash, check, credit, debit, or HSA/FSA cards, Venmo.
• If patients are unable to pay at the time of service, payment will be expected prior to or at the next appointment. If payment is not received prior to or at the next appointment, all future appointments will be canceled.
• Aspire Medical Group reserves the right to absorb credit balances less than $10.

• Aspire Medical Group understands the value of patient time and appreciates the same consideration in return. Our office provides appointment reminders via text or phone to assist in this effort. If a patient must cancel an appointment, a minimum of 24-hour notice is requested.
• Failure to provide 24-hour notice to cancel a scheduled appointment with our office will be considered a late cancellation. Failure to arrive within 20 minutes of the start time of an appointment will be considered a missed appointment/no show.
• Every effort will be made to reschedule the first late cancellation/missed appointment.
• If a second consecutive appointment is canceled late/missed, or 3 appointments are canceled late/missed within 60 days of the first late cancel/missed appointment, all future appointments will be canceled, and a patient will receive a letter with information about choices for ongoing treatment.
• Frequent cancellations, even with 24-hour notice, may also result in the suspension of treatment.
• Repeated instances of no-shows and late cancellations not made in accordance with our company policies will result in a written warning after the 2nd offense. After the 3rd offense, it will be considered just cause for termination, and your chart will be closed with our practice.
• Please cancel any appointments that you cannot make with at least 24-hour advance notice to avoid being counted as a "no-show" and incurring the following fees:
• Less than 24 hours before an intake appointment will incur a $100 fee
• Less than 24 hours before a follow-up appointment will incur a $50 fee
• Payment for missed or canceled appointments is the responsibility of the financially responsible party since insurance companies do not pay for missed appointments. Payment for missed or late canceled appointments is expected at the patient’s next scheduled appointment.

Please allow 3 business days for processing. It is your responsibility to notify our clinic at least 72 hours prior to running out of medicine.

Medication refills will be made only at the time of an office visit or during regular office hours. If you do not have a future appointment scheduled when a refill request is made, then your request will not be processed until you have done so.
Refills generally will not be given after office hours, during weekends, or on holidays, so please schedule your appointments accordingly.

Plan Ahead:

Anticipate your prescription refill needs and make sure you have an adequate supply of medication to last through weekends and holidays. Take into account any upcoming vacations or holidays when healthcare providers may have limited availability.

Please do not contact providers directly after business hours, on weekends, or during holidays for requesting prescription refills. Contacting providers directly during these times for non-urgent matters, such as requesting emergency prescription refills, may disrupt their personal time and prevent them from fully recharging and being available for emergencies and critical patient needs.

If you run out of medication when our office is closed, please go to the nearest emergency room if your health is at risk. Any messages left on our answering machine will not be checked until the next business day and cannot be used for rapid communication after business hours.

Contact your insurance company to verify that the provider you will be seeing is in-network with them.

We are in-network with many but not all insurance carriers. We need up-to-date insurance information to bill your carrier. You are responsible for knowing the terms and conditions required of you and for the payment of all fees including co-payments and deductibles.

Provide accurate insurance information prior to the service. 

Obtain any necessary referrals from your PCP if required by your insurance company prior to your initial appointment. If we do not receive confirmation that the referral was approved, your appointment will be canceled until we receive it.
Aspire Medical Group needs to be notified whenever you change carriers to ensure smooth coverage transition and avoid uncovered charges. You will be responsible for payment of any services not covered by your insurance carrier. If you do not have up-to-date insurance information, we will reschedule your appointment or classify your appointment as self-pay.

Services not covered by insurance will incur out-of-pocket fees:
In the event you request or require a provider from Aspire Medical Group by subpoena to provide ancillary professional services in a criminal or civil matter, you agree to compensate Aspire Medical Group in advance at the rate of $250.00 per hour. This may include activities such as preparation of treatment summaries, report writing, attendance, and travel time.

• T.O.V.A. ADHD Testing
• FMLA Evaluation
• Disability/RMV Evaluations
• Ketamine Infusion Therapy
• IV Hydration 
• Wellness/ Vitamin Injections
• Emergency Procedures

Aspire Medical Group maintains a 24-hour phone and secure messaging service, however, we are not a 24-hour facility. You may leave a confidential message at any time using our phone system. If you are having a life-threatening emergency and cannot safely wait for a response from our clinician, please go to the nearest emergency room for immediate assistance. 

• I certify that I have read this form in its entirety and fully understand its contents. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. All my questions have been answered to my satisfaction.
• By signing this form, I voluntarily consent to treatment and agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.
• I agree to abide by the office policies outlined above, including but not limited to billing, payment, cancellations, prescription refills, and insurance responsibilities.
• I am signing this form voluntarily, and I confirm that I have the full legal authority to be bound by this agreement.
• By signing, I voluntarily give my consent for treatment and accept the risks, conditions, and terms outlined in this document.

By providing my electronic signature below, I agree to the terms and conditions outlined in this financial agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

The parties acknowledge and agree that this financial agreement form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.