Consultation Fee Schedule ST-2a Detailed Pre-Treatment Consultation This consultation with an INR PLLC medical provider will include a review of patient history, review of potential treatment options, and discussion of the potential suitability of anti-TNF treatment. Cost of Consultation: $1000.00 USD Policies: Payment in full prior to the consultation is required. The full consultation fee is final and non-refundable regardless of the treatment modality chosen or even if non-treatment is elected. Fees quoted are subject to increase at anytime. Cancellation Policy: 48 business hours (Monday through Friday) notice is required for all appointment cancellations. If appropriate notice of cancellation is not given, the entire $1000.00 USD fee is forfeited. Please be advised that our office does not participate with Medicare or any other insurance program. Fees are the responsibility of the patient/caregiver. Since the FDA has not approved this procedure and medication for this use, insurance reimbursement for the consultation or the procedure is not to be expected. I understand that the INR PLLC medical director is certified by the American Board of Internal Medicine and not board-certified in Neurology. I understand that the INR is a private practice. I understand that consultation does not guarantee that treatment will be recommended for me. I understand that I have no obligation to choose treatment, even if it is recommended. I have read the above fee policies and agree to them. I understand this fee reserves my consultation time as scheduled and is non-refundable. I agree to be responsible fully for all charges incurred.Patient Signature* First Name Last Name By typing my name in the above below I agree that my electronic signature shall be valid for the purposes of this document.Date* MM slash DD slash YYYY Cargiver Signature* First Name Last Name By typing my name in the field above I agree that my electronic signature shall be valid for the purposes of this document. Date* MM slash DD slash YYYY Δ
