The Body Modis a Direct Patient Care practice and is not a provider for any type of insurance. We are a self-pay clinic andDO NOT ACCEPT OR BILL ANY TYPE OF HEALTH INSURANCE.Payment is due at the time services are rendered and accepted in the form of cash, check, credit card, debit card, or FSA/HSA.

• By choosing this model, we are able to provide patients with comprehensive and individualized care while avoiding unnecessary struggles with health insurance restrictions and requirements. All of our services must be paid for at the time the services are rendered.
• With high deductibles and insurance coverage picking up costs onlyafterutilizing and failing first-line treatment options, the cash price is often less than your cost using your insurance. In addition, many adjunct therapies are not covered by insurance which limits your healthcare options. By eliminating this barrier, you’ll receive individualized treatment plans, support, accountability, and expertise which equates to accessible care at a great value.

You may be able to use pre-tax dollars from a Health Savings Account (HSA) or a Flexible Spending Account (FSA) to pay for your fees related to your services from this office. Please contact your insurance company with any questions or concerns regarding covered amounts and deductibles. We can provide you an invoice to submit for out-of-network reimbursement to your insurance, but that will be your responsibility.

OUR OFFICE CANNOT ASSIST YOU WITH ANY CLAIM RESOLUTION.

Consultation fee is $199 and is due in full when scheduling your appointment. Your consultation fee includes a$50 non-refundabledeposit. It is preferred that diagnostic testing be completed prior to your Initial Consultation, so that we can review your lab results and go over your treatment plan options.

• Upon scheduling your appointment, you will receive a confirmation email with links to several forms that must be filled out prior to your appointment.
• Please complete the demographic information, the clinical profile, and patient intake formAT LEAST 24 HOURSprior to your consultation.
• If your forms have not been completed in a timely manner, your appointment will be rescheduled and a$50 late-cancellation feewill apply.

New patients who miss their scheduled appointment will result in forfeiture of the prepaid services.

Your initial consultation will typically take60 minutesand will include:

• A review of your medical, family, and surgical history provided in your completed medical forms
• A head-to-toe physical examination
• An in-depth discussion regarding problematic symptoms, health risks, and treatment goals
• Review of diagnostic testing results (cost of lab work is not included in price of consultation)*
• A personalized treatment plan will be determined based upon finalized lab results
• Education on risk factors, benefits, and alternatives of therapy

The main objectives of the consultation are to determine if you are a candidate for hormone replacement therapy, thyroid optimization, and/or GLP-1 Peptide Therapy and if we can provide the services needed to optimize your health.

In order to offer affordable monthly subscription plans, diagnostic testing and monitoring isNOTincluded in the monthly subscription as it is personalized to each individual.

• Please note that venipuncture is not performed on site, at this time. We are currently in the process of organizing that venture and hope to be able to offer this service in the very near future.
• We request that diagnostic testing is completed prior to the initial consultation to make the best use of our time together. However, if time is not permitting, an order will be sent after your Initial Consultation.
• We will also accept lab results from other providers within the last 6 months.
  • • Results can be faxed to 937-202-4473.
    • You can provide a one-time share code to MyChart. Please contact the office for instructions as a provider must be available at the time of request since the code is only valid for 1 hour.
• We can refer you to the facility of your choice and use your health insurance to cover the cost (if applicable) or you can take advantage of deeply discounted rates available from our partner companies. It isYOURresponsibility to contact your insurance company with any questions or concerns regarding covered services, amounts, and deductibles. Please be aware that you are liable for the costs associated with the diagnostic tests.

OUR OFFICE CANNOT ASSIST YOU WITH ANY CLAIM RESOLUTION.

Women’s Health [Bio-Identical Hormone Replacement Therapy (BHRT)], Men’s Health [Testosterone Replacement Therapy (TRT)], thyroid optimization treatment, and GLP-1 Peptide Therapy require a subscription package to ensure continuity of care for optimal health improvement. It is also necessary to avoid possible delays or lapses in treatment due to shipping, holidays, etc. You choose any add-on services and/or recommended supplements, they are not required. After the initial consultation and lab work have been completed, there is no other financial commitment until YOUchoose to start treatment.

Patient-specific specialty medication from a 503A pharmacy is delivered to the office at no additional charge to you. However, if you request home delivery of specialty medication, you will assessed a $35 delivery fee.

A $100 fee will be assessed if your insurance carrier requires a prior authorization for the requested medication. It is suggested that you reach out to your insurance carrier and specifically ask about your coverage for any medications prior to initiating any subscription. No refunds will be provided for prior authorizations that are denied by your insurance company.

We offer 4 week and 12 week recurring subscriptions which can be canceled at any time with a 30-day written notice.

The Body Modhasa 24-hour cancellation policy.

When you schedule an appointment with us, this appointment time is set aside especially for you. It is not available to other patients. Therefore, it is important that you let your practitioner know as soon as possible if you will be unable to come to your scheduled appointment. This allows us to make this time available to other patients. As a courtesy to the providers at The Body Mod and other patients, please provide adequate notice (24 business hours for follow-up appointments and preferably 48 business hours for new patient appointments) if you need to cancel or change an appointment.

• Cancellation/Rescheduling Policy:You may cancel or reschedule your appointment in a timely manner via the Patient Portal or by calling the office. Out of courtesy to other patients and our providers, we ask that you please notify the office as soon as possible if you need to cancel or reschedule your appointment. If you do not provide adequate notice, you will need to call the office and you will be charged a$50 late-cancellation feeto the authorized card on file.
  • • • Voicemail or text messages left after hours the day before your scheduled appointment will be considered a late-cancellation and will result in a late-cancellation fee.
      • For New Patients:
        • • Failure to complete required consent, medical history, and demographic information forms 24 hours prior to an Initial Consultation will result in automatic cancellation of the Initial Consultation and a$50 late-cancellation feewill be deducted from the previously paid consultation fee. As a result, you will need to contact the office at 937-530-0070 to complete an additional $50 payment for your Initial Consultation fees in order to reschedule your appointment.
      • A second offense of late-cancellation can result in dismissal from the practice.
• Late Arrival Policy:Late appointments are a challenge to maintaining a schedule with both our provider and other patients. If you know you are going to be late, please let us know as soon as possible, and we will try our best to accommodate before rescheduling and assessing the late-cancellation fee. Arriving 10+ minutes late may result in a cancelled appointment for which we will charge the above-mentioned$50 late-cancellation fee.
  • • • As a courtesy to you, we understand that your time is valuable as well, so we will do our very best to stay on schedule.
      • Patients who habitually arrive late can be dismissed from the practice after the second offense.
      • For New Patients:
        • • Arriving less than 30 minutes late to your Initial Consultation will result in a condensed appointment which may require scheduling a follow-up appointment for a thorough review, depending on complexity of concerns.
          • Arriving 30+ minutes late to your Initial Consultation will result in automatic cancellation of the Initial Consultation and a$50 late-cancellation feewill be deducted from the previously paid consultation fee. As a result, you will need to contact the office to complete an additional $50 payment for your Initial Consultation fees in order to reschedule your appointment.
• No-Call, No-Show Policy:If you fail to show up for an appointment without notification, you will be charged a$50 no-show feeto the authorized card on file and written acknowledgement of concern with a copy of the policy.
  • • • A second offense of no-call, no-show will result in dismissal from the practice.
      • For New Patients:
        • • • If you fail to show for an appointment without notice, you willforfeit your entire prepaid consultation fee.As a result, you will need to contact the office at 937-530-0070 to complete an additional $199 payment for your Initial Consultation fees in order to reschedule your appointment.
• True emergencies are the exception to this policy.In the event of a true emergency, this policy will be waived. Please note: work and school-related demands or obligations are not considered true emergencies.

While we do provide appointment reminder notifications, please be aware that this is provided as a courtesy to you. It is not our responsibility nor an excuse for missing an appointment.

We do not want late-cancellations or missed appointment fees to be an impediment to your care and so we ask for your mutual respect. When you make an appointment, we block out our schedule for you and ask that you exercise the same consideration when planning your calendar. Thank you for your respect and understanding.

A 503A compounding pharmacy is a specialty pharmacy (under the direction of a licensed pharmacist) that formulates and prepares customized prescribed medications to specifically meet the patient’s needs. All compounded medications are patient-specific.

Women’s Health and Men’s Health patients, diagnostic testing will need to be done to monitor your levels at 6-8 weeks after initiation and/or adjustment of treatment. The office will notify you once results are in to schedule a follow-up appointment. At that time, we will review results and discuss any adjustments to your treatment plan. Once you are stable in your treatment plan, labs are monitored every 3-6 months and you will be seen every 3-6 months.

For GLP-1 Peptide Therapy patients, you will need to be seen monthly. Lab work monitoring will occur every 3-6 months or as needed.

We offer virtual follow-up visits for your convenience.

Payments are automatically processed based on your chosen subscription. Monthly payments recur every 4 weeks and quarterly payments recur every 12 weeks (determined by the date of your initial consultation), through a secured auto-payment system to the credit card on file.

Same-Day Billing Option is available by request and does increase the price monthly, but not the overall cost of services. Inquire for more details.

If non-payment occurs for any reason, an additional $25 fee will apply. If you need to change or update the card on file, you may do so through your Patient Portal. It isyourresponsibility to ensure the information for the card on file is correct.

There is a 3-month minimum commitment with any subscription service. You may cancel the subscription at any time afterwards, but we do require a30-day notice in writing. You may continue to use the services of your membership after submitting the request to cancel until the last day of your paid subscription. Prescription refill at the local pharmacy may be done by submitting a request in Messages in your Patient Portal during your last 30 days. If you are due, your last refill of specialty medication will be placed on the day the notice is received. Patient-specific 503A specialty medication will not be refilled afterthe cancellation notice is received.

Due to the nature of the services provided by The Body Mod, all sales are final, and no refunds will be issued. Services must be utilized within the designated timeframe, as they are non-transferable and non-refundable. Please note that refunds will not be provided for dissatisfaction with results, as individual outcomes may vary based on adherence and personal factors.

Due to the nature of the personalization of your 503A patient-specific specialty prescriptions, in the event that you cannot tolerate or do not wish to take the medication customized for you, the coordinated pharmacy is not able to accept any returns or offer any refunds, regardless of satisfaction or results achieved.