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.