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Medical Records Release & Request Form

This form authorizes your health service provider to submit your medical record (or specific portions of it) to Ketamine Wellness Centers.

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.

Patient Information:

Patient's Name(Required)
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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)
(e.g. further care, insurance claim, attorney inquiry, at the request of the individual, personal use, etc.)

Select your Ketamine Wellness Centers Clinic:

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.

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If I fail to specify an expiration date, event, or condition, this authorization will expire in ninety (90) days.

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.

Reset signature Signature locked. Reset to sign again
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Name of Legal Representative or Guardian if Patient is a minor