Baltimore Ketamine Clinic

Home Medical History

Our practice is dedicated to your health. We offer appointments at your convenient time. In order to prepare for your FIRST appointment we ask you to please fill out the following two forms online.

PRACTICE POLICY
We wish to take this opportunity to welcome you and state some basic principles we believe are essential in establishing a good relationship between us. Please read through this information, asking questions as needed.

INITIAL INTERVIEW: Your first history and physical is considered an evaluation interview and exam. At the time of this appointment, the following decisions will be made with you:

• If ketamine is an appropriate treatment option
• Frequency and duration of ketamine infusion sessions
• Goals of therapy (what you hope to gain from this process.)

APPOINTMENTS: Each appointment varies in length depending on your chief complaint. Typically, 40-minute infusion appointments take just under 2 hours, 4 hour infusions are typically around 5 hours long. At the end of each appointment you can make arrangement for your next appointment or you may book all your prescribed appointments at once.

CANCELLATIONS: If you find that you need to cancel an appointment, please give as much notice as possible so that we can schedule people that are on our waiting list. You will be personally charged for your appointment if not canceled at least 24 hours in advance other than for emergency reasons.

PAYMENTS: We would greatly appreciate payment in full for each office visit prior to the start of your appointment. If you do not have a charge card we will accept cash and check. Please make checks payable to “Baltimore Ketamine Clinic”.

INSURANCE: Insurance is an agreement between you and your insurance company as to how treatment will be paid for. We will assist you in any way possible by providing receipts and documentation. We currently do not directly participate with insurance plans. However, we will assist you by giving you receipts to submit, and follow up contacts. Some insurance companies will pay for a portion of outpatient ketamine infusion services. You should check with your insurance company representative to find out specific requirements and limitations of this coverage. We will be happy to assist you in the preparation of insurance forms if you feel there is a chance your insurance company will pay for these services. Payments for services received through Baltimore Ketamine Clinic are ultimately your responsibility. If your insurance company requires that outpatient ketamine infusion services be preauthorized, it is your responsibility to initiate the preauthorization process, i.e. contacting your primary care physician, insurance company, or a third party “gate keeper”. Failure to obtain required preauthorization for outpatient ketamine infusion services will result in you being held 100% responsible for all charges.

CONFIDENTIALITY: All information regarding the specific nature of your treatment is maintained at Baltimore Ketamine Clinic and is considered confidential within the office, unless specified by you in writing. However, each provider at this office reserves the right to use specialty consultation with other medical providers at the office as deemed necessary. We follow HIPAA and maintain confidentiality.
Please check the following boxes:

I acknowledge that I have read and understand all of the foregoing statements and that my signature below indicates that I agree to abide by all of the above conditions.

I have received a copy of the Privacy Practices Form.

I consent to the exchange of treatment information between Baltimore Ketamine Clinic and my primary care, mental health, or pain management provider.