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.