Delic Announces Pending Acquisition of KWC by Peter/PetraMD - Patients Please Contact Us For More Information

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.

  • 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.

  • MM slash DD slash YYYY
  • Reset signature Signature locked. Reset to sign again