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.
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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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Ketamine Wellness Centers

Ketamine Wellness Center’s mission is to provide personalized, compassionate, high-quality care for people suffering from afflictions where Ketamine infusions have proven a successful treatment option (Depression, Chronic Pain, PTSD, OCD, Suicidality) while actively researching Ketamine’s efficacy to treat additional conditions. There is hope. There is help.

PHONE:
855-KET-WELL (1-855-538-9355)

FAX:
844-KET-WELL (1-844-538-9355)

EMAIL:
info@ketaminewellnesscenters.com

CLINIC LOCATIONS:

Chicago, Illinois
603 E Diehl Rd, Suite #139 Naperville, IL 60563

Dallas-Fort Worth, Texas
6144 Precinct Line Road, Suite 100 Hurst, TX 76054

Denver, Colorado
7261 S Broadway, Suite 10-L Littleton, CO 80122

Houston, Texas
12807 Haynes Rd. Building A, Unit 1 Houston, TX 77066

Jacksonville, Florida
3753-2 Cardinal Point Drive Jacksonville, FL 32257

Las Vegas, Nevada
7375 S. Pecos Rd. Suite 102 Las Vegas, NV 89120

Minneapolis-St Paul, Minnesota
11995 County Road 11, Suite 220 Burnsville, MN 55337

Mesa-Gilbert, Arizona
2451 E. Baseline Rd, Suite 300 Gilbert, AZ 85234

Phoenix, Arizona
3724 N 3rd. St. Suite 201 Phoenix, AZ 85012

Reno, Nevada
1895 Plumas St. #6 Reno, NV 89509

Salt Lake City, Utah
6087 S. Redwood Road STE. B Taylorsville, UT

Seattle, Washington
34709 9th Ave S. Suite-B 200 Federal Way, WA 98003

Tucson, Arizona
3130 N Swan Rd. Tucson, AZ 85712