I have chosen to receive medical services from Dr Enter Name, I understand that my insurance benefits cannot be verified at this me.I understand I am responsible for all deductibles, copayments and non-covered expenses, and other out -of-network expenses incurred by seeking services by a nonpreferred/out-of-network provider. I am also aware that any outside services (labs, ultrasounds, mammograms, hospital care, etc.) ordered by the physician are also subject to out-of-network reimbursement depending on my individual plan according to my insurance carrier.