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.
Leave this empty:
Your legal name
Your email address
Signed by POST PT Luke Ferdinands
Signed On: November 24, 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Agreement to Self Pay/Waiver for Insurance Exclusions
Agree & Sign