Patient Information: Patient's Name (Required)
(Required) Release from Health Service Provider to Ketamine Wellness Centers Provider Address
I am requesting the provider listed above to release the following information to Ketamine Wellness Centers: The specific information to be used or disclosed is as follows: (Required) If you selected Other, please specify: For the purpose of: (Required)
(e.g. further care, insurance claim, attorney inquiry, at the request of the individual, personal use, etc.)
Select your Ketamine Wellness Centers Clinic: KWC Clinic Locations (Required) Mesa, Arizona Tucson, Arizona Denver, Colorado Seattle, Washington Chicago, Illinois Minneapolis, Minnesota Dallas, Texas Houston, Texas Jacksonville, Florida Las Vegas, Nevada Salt Lake City, Utah
Phone: 855.KET.WELL | Fax: 844.KETWELL
Disclosures & Authorization
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.
By signing below, I hereby authorize the above use and disclosure. (Signature of patient or Legally Authorized Representative.)
Signature locked. Reset to sign again
Name of Legal Representative or Guardian if Patient is a minor