Insurance Waiver Form

If you have any questions about this form, our staff is available during regular business hours (Mon – Fri, 9am – 6pm) to assist. Call us at 855-KET-WELL.

Acknowledgment that Ketamine Wellness Centers will not bill insurance companies directly for treatment coverage.

I acknowledge that I will not have Ketamine Wellness Centers bill my insurance plan/coverage for treatments.*
This agreement will be active until written notice is given to Ketamine Wellness Centers billing office. This agreement is valid from the following treatment start date:*
MM slash DD slash YYYY
I understand that I will be able to receive Superbills to self-submit claims to my insurance if my plan allows for self-submitted claims. I am agreeing to pay the cash price per visit as listed on the company’s website. I further understand that if I provide a written request to revoke this notice and Ketamine Wellness Centers is not contracted with my insurance that I will not be able to be seen until Ketamine Wellness Centers becomes contracted.
Date*
MM slash DD slash YYYY
Patient Signature
If the signature box does not appear above, enter your full name below. By entering your name electronically, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this form
CAPTCHA

Insurance Waiver Form

Contact Us

Latest Posts

“Hugely Encouraging”: Researchers Investigate Ketamine Therapy for Gambling Disorder

Choosing the Perfect Playlist for Ketamine Infusion Therapy