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Agreement to Self Pay/Waiver for Insurance Exclusions

POST Physical Therapy (POST) believes that your insurance plan may not pay for your treatment(s) or service(s), which may result in direct costs to you. You are responsible for verifying your health plan coverage with your insurer. This form is to help you make an informed choice about whether or not you want to receive treatment or services, knowing that you might have to pay for them yourself. If needed, please ask for an ESTIMATED COST for the items or services you may receive at POST

Reasons for Signed Waiver: Please select checkbox(es) that apply and sign at bottom.

Self Pay
No referral/RX
Pending Authorization
Not Eligible/Out(Max) of Benefits
3rd Party / Attorney Liens
Other
Description of Other

I understand and accept that I am financially responsible as checked above, for services rendered at POST.

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Your legal name

Your email address

Please Confirm full name and signature.

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I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

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Signed by POST PT Luke Ferdinands
Signed On: January 19, 2023

Timestamp

Audit

October 27, 2020 2:42 pm EDT

Agreement to Self Pay/Waiver for Insurance Exclusions Uploaded by POST PT Luke Ferdinands - info@postpt.com IP 96.237.59.139