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.

Patient Information:

Patient's Name(Required)

First Last

Date of Birth:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Release from Health Service Provider to Ketamine Wellness Centers

Health Service Provider Name(Required)

Provider Phone

Provider Fax

Provider Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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)

Intake & History

Discharge Summary

Treatment Progress

Verbal Consultation

Diagnosis & Treatment Plan

Billing & Payment

Other

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)

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.

This authorization is valid until:(Required)

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.

By signing below, I hereby authorize the above use and disclosure. (Signature of patient or Legally Authorized Representative.)

If the signature box does not appear above, enter your full name below. By entering your name electronically, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this form

Date

Name of Legal Representative or Guardian if the Patient is a minor.

First Last

Representative's relationship to Patient

CAPTCHA

PHONE:
855-KET-WELL (1-855-538-9355)
FAX:
844-KET-WELL (1-844-538-9355)
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
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
Seattle, Washington
34709 9th Ave S. Suite-B 200 Federal Way, WA 98003
Tucson, Arizona
3130 N Swan Rd. Tucson, AZ 85712
Las Vegas, Nevada
7375 S. Pecos Rd. Suite 102 Las Vegas, NV 89120
Salt Lake City, Utah
6087 S. Redwood Road STE. B Taylorsville, UT 84123
Phoenix, Arizona
3724 N 3rd. St. Suite 201 Phoenix, AZ 85012
Reno, Nevada
1895 Plumas St. #6 Reno, NV 89509

Find us on: