This form authorizes your health service provider to submit your medical record (or specific portions of it) to Ketamine Wellness Centers.
Phone: 855.KET.WELL | Fax: 844.KETWELL
I understand that the information in my health record may include information related to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand that I have a right to revoke this authorization, in writing to Ketamine Wellness Centers, at any time. I understand that the revocation will not apply to information that has already been released in response to this authorization.
I understand that this authorization is voluntary. I can refuse to sign this authorization. I understand that I have a right to inspect and copy the information to be used or disclosed pursuant to this authorization.