Client Election to Self Pay for Services
Please read the following information and only sign if you have read, understood and agree to abide by the terms listed below.
Client's Date of Birth
Election to Self Pay
I, the undersigned client, acknowledge that I understand and agree that:
A New Hope Therapy Center is a participating provider with my insurance carrier.
Despite the above, I do not wish A New Hope Therapy Center to submit a claim to my insurance company for services provided to me by A New Hope Therapy Center.
Until such time as I may otherwise advise A New Hope Therapy Center in writing, I elect to pay for all services I receive from A New Hope Therapy Center at their out of pocket rate.
By election to self-pay for services, any payments I make to A New Hope Therapy Center will not be credited toward satisfying any deductible I may be subject to under my health insurance plan unless otherwise permitted under the terms of my health plan.
I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.
I have freely chosen to self-pay for services after having asked A New Hope Therapy Center about payment options and having carefully considered those options.
Typing your full name indicates consent and agreement:
Send me a copy of my responses.
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This form was created inside of A New Hope Therapy Center.