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 *

Phone

County *

Has Insurance?

No Yes

Mailing Address

Clinical Information

Current and Past Diagnoses *

Does this client have schizophrenia, schizoaffective disorder, or bipolar disorder with psychotic features? *

No Yes

Services Requested

No services are currently available.

Additional Information

Why do you think KAP would be appropriate and beneficial for this patient? *

Has your client received ketamine therapy in any form in the past? If so, please describe.

What is your understanding of the financial hardship this client is experiencing?

Which funding course would you recommend? *

If partially funded, what percentage can your client pay?

Do you have any concerns regarding engagement in treatment? *

Where is the patient planning to obtain services from? *

Please include a short biography of your patient or client, including relevant background and circumstances. *

I acknowledge that funding awarded is transferred directly to the service provider, not to the patient or referring provider.

Clinical Notes

Physician notes / clinical justification