Insurance Waiver Form

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

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