Non-Covered Services Agreement

Non-Covered Services Agreement
Important Note: You are not required to complete this form electronically. If you would prefer a paper copy to complete, please call us at (919) 600-4906.

Health insurance companies do not cover everything, even some services you and your health care provider feel you need. We have reason to believe that a service you are seeking may not be covered under your health plan.

You have the option of proceeding with this service and paying us directly and in full. We are required to obtain your written acknowledgement before we can proceed.
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
Date
Is this patient a minor (under age 18) or a legally dependent adult? *

Yes No
A parent or legally appointed guardian of a minor child must sign this form. A step parent is not a legal guardian.

The legally appointed guardian of a dependent adult must sign this form.
Name of parent or legal guardian signing this form *

First Name Last Name

My Etheridge Psychology provider's name *

First Name Last Name
Provider Contact Information

Etheridge Psychology, P.A.
115 Kildaire Park Drive, Suite 313
Cary, North Carolina 27518
Phone: (919) 600-4906
If you request us to do so, we can file a health insurance claim for you despite knowing the services may not be covered in the hope that they will decide to cover it. If your insurance company does reimburse us, we will refund you the amount the insurance company paid to us in the event that the insurance company approves payment. You will receive your refund once we receive payment from the insurance company, which can take weeks to months.

By signing this document, you acknowledge that you have been notified prior to the services being rendered that the services you have requested may not be covered by your health insurance or you have requested that we do not file a claim.

You also agree that, if not covered by your health insurance plan, these services are provided at your own expense and apart from your health insurance plan if you elect to receive the specific services. You agree to pay the full cost of the services to be performed directly to Etheridge Psychology, P.A.
Electronic Signature

By completing the following fields, you affirm that you have read this document, that you agree to the terms and conditions, and that you consent to sign this document electronically. You are not required to sign electronically and may request this document in non-electronic form. You have the right to withdraw your consent to further electronic disclosures, in writing, at any time. You have the right to receive a copy of your completed form. You may reach us by phone at (919) 600-4906, and our address is 115 Kildaire Park Dr Ste 313, Cary, NC 27518. If you are signing this document on behalf of a legal dependent (such as a minor child), you attest that you have the legal authority to sign on behalf of this patient without the approval of another person (such as a minor's other parent).
Signature of Patient or Legal Guardian *

Clear
Name of person electronically signing this document *

First Name Last Name
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