Health Insurance Opt-Out Form

Choices Mental Health Counseling PLLC

Narrowsburg, NY 12764
Health Insurance Opt-Out
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
I have elected to not use my insurance for my counseling sessions.

I understand that choosing to opt-out of using my insurance means I must pay out of pocket for the counseling sessions on or before the date of service.

I have made my therapist aware that I have chosen to not use my insurance for counseling sessions, effective on the date specified below, regardless of whether he is in- or out-of-network with my plan.

I will inform my therapist in writing if: (1) I obtain alternative health insurance coverage that I would like to be billed for my sessions; and/or (2) I decide that would like my sessions billed to my current insurance plan.
Current Health Insurance Plan*
Effective Date of Insurance Plan Opt-Out:*

MonthDayYear
Date
Signature*

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