Opt Out Insurance Form

Opt Out Insurance Form
Please initial each item:
I have selected to not use my insurance for my counseling sessions.*

Clear
I understand that opting out of using my insurance means I must pay out of pocket for the counseling sessions.*

Clear
I have made my therapist aware that I have opted to not use my insurance for counseling sessions even if she/he is in network or out of network.*

Clear
I have agreed to let my therapist know if anything changes and I either obtain alternative insurance and or decide that I would like my sessions billed to my insurance.*

Clear
I understand that if I opt out of using my insurance I cannot use the payment of sessions towards my deductible because I have elected to opt out of using my insurance.*

Clear
I understand that if I choose to later use my insurance my therapist is not liable and is not obligated to reimburse previous sessions where I have chosen to opt out of billing my insurance. My opt in to use insurance will start from the day I notify my therapist of the change and cannot be backdated to previous sessions.*

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Consumer Signature*

Clear
Today's Date*

MonthDayYear
Date
Your Name*

First NameLast Name
Your Email Addres*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Your Date of Birth*

MonthDayYear
Date
Should be Empty:

Please initial each item: