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Physician Application for Patient Funding
Submit a funding request for ketamine-assisted therapy on behalf of your patient.
Physician Information
Name
*
Email
*
Phone
NPI Number
Patient Information
First Name
*
Last Name
*
Email
Phone
County
*
Select county...
Humboldt
Del Norte
Trinity
Has Insurance?
No
Yes
Services Requested
IV Ketamine Treatment
$500.00
IM Ketamine Treatment
$350.00
Sublingual Ketamine Treatment
$250.00
Psychotherapy Session
$200.00
Insurance eligible
Psychiatric Evaluation
$300.00
Insurance eligible
Integration Session
$150.00
Clinical Notes
Physician notes / clinical justification
Submit Application
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