THE BODY PROJECT @ ASCEND Selection of the program level that best fits your needs!
1. Natural, functional approach without medications / Insurance-based or other practice-ordered medication support program - includes required monthly InBody/nurse check-in appointments, symptom, and diet support. (3-month minimum, medical appointments required every 3 months) ** $65 monthly membership initial: ______________ We prior authorize all medications prescribed to seek out Insurance coverage, The above level of Cash Option: Direct Access Wegovy $499/month - Novocare Cash Option: Direct Access Zepbound $499/month - Lily Direct If commercially prepared doses are not tolerated, we order compounded medications in microdose increases. 2. Full Support plus SEMAGLUTIDE/B12 Injections included, + one Lipotropic injection, InBody (medical appointments required every 3 months) ** $425 monthly initial: ______________ ⃞ Transition Dosing to bridge Insurance Prior Authorization (SEMAGLUTIDE/B12 microdose) - $100 per injection (1st month only) weight loss support is required if insurance is covering medications. We believe close follow-up and support is essential to long-term success. -All required labs will be ordered and included in the cost at start of program and every 6 months (if cash pay). -Provider appointments will be sent thru insurance for BCBS and Sanford or at day of service cash pay rates without insurance. Please check with your insurance company regarding coverage. These may not be covered for weight loss, Your primary provider can send referral for weight loss/nutritional assistance in some cases to approve coverage. It is important to know your insurance coverage. -Provider appointment day of service cash pay rates: Initial- $295 and Followup- $100 and InBody analysis $35 -Mailed requests: $25 cost will be charged. -Further labs or supplements or labs recommended are an additional cost- all on a case-by-case basis and will be discussed as needed. I understand the full program details after discussing all options with my provider @ ASCEND. I have selected the above program support level and choose to proceed with the Body Project. I understand that level 1 or any home dosing requires a 3-month minimum of automatic monthly payments before cancellation and that cancellation requests must be emailed to ascendwellnessmbs@gmail.com 30 days prior to the next processing date to process cancellation appropriately. A separate credit card authorization form will be completed. I consent to initiating the program, risks/benefits have been explained and all of my questions have been answered. __________________________________________ Printed Name: __________________________________________ ___________________________ Signature: Date:
We look forward to supporting your journey to better health! Ascend Wellness MBS
www.ascendwellnessmbs.com
rev 7/25
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