self-pay election

1. VOLUNTARY CHOICE TO DECLINE USE OF INSURANCE. By signing this form, I confirm:

  • I am choosing of my own free will NOT to use my in-network mental health benefits for services with this therapist.

  • I am requesting to be treated as a self-pay client from this date forward, even though the therapist remains in-network until the contract termination date.

  • I am not being coerced, pressured, or incentivized to decline insurance.

 

2. FINANCIAL RESPONSIBILITY. I understand and agree that:

  • I will pay the therapist’s private-pay rate agreed upon for all services rendered.

  • These rates are disclosed in the Good Faith Estimate, which I will receive and review.

  • These payments cannot be submitted by my therapist to my insurance.

  • Out-of-network reimbursement is not guaranteed and is solely determined by my insurance plan.

 

3. PRIVACY CONSIDERATIONS. I understand:

  • When I pay privately, no clinical information is shared with my insurance company.

  • This may improve my privacy and prevent additional diagnostic information from entering my permanent medical/insurance record.

 

4. DURATION OF ELECTION. This self-pay election until I revoke this election in writing, understanding that claims cannot be back-submitted for sessions I previously paid for out-of-pocket.