Waiver for Non-covered Services

Waiver for Non-Covered Services:

I understand that today I am receiving services that may or may not be covered by my insurance company. The office of Bay Street Pediatrics has notified me that these procedures may not be covered by my insurance company.
Patient Name:

First Name Last Name
DOB

Month Day Year
Date
Impact Baseline Test (Baseline Test: to be paid at the time of service): Fee $35.00

Agree to service
Impact Test (Concussion Follow Up Test): Fee $75.00

Agree to service
Pre Travel Consultation: Fee $65.00

Agree to service
If I have requested that this service be performed, I agree to be personally responsible for payment of this service should the claim items be denied by my insurance company
Signature

Clear
Today's date
Reminder

Please remember to check with your insurance company before having any services to make sure they are covered. If you do not have an insurance handbook, please contact your insurance company to obtain one.
Should be Empty:

Waiver for Non-Covered Services: