Authorization for Release/Exchange of Information

Authorization for Communication Form

This form provides Ketamine Wellness Center's therapist and clinical staff with written permission to communicate with other individuals regarding your treatment (e.g. previous therapist, current health care providers, parent, spouse).

I, ___________ authorize Ketamine Wellness Center’s staff to communicate and/or exchange information about my case with the following parties:*
Authorized Party
Please provide the details of the party who Ketamine Wellness Centers will communicate information about your case to.
Name*
First Last
Relationship*
Phone*
Fax
Information to be Released or Exchanged (check all that apply):*
- Intake & History
- Discharge Summary
- Treatment Progress
- Verbal Consultation
- Diagnosis & Treatment Plan
- Billing & Payment
- All of the above
- Other
If you selected Other, please specify:
Date*
MM slash DD slash YYYY
Patient Name:*
First Last
Patient Signature*
or Parent Signature (if patient is a minor):
This release shall be valid while under the care of Ketamine Wellness Centers, Inc. or until withdrawn in writing by the patient during the course of treatment.

Authorization for Communication Form

Authorized Party