Agreement to Self Pay/Waiver for Insurance Exclusions

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
Patient's Name*
First Last
Email*
Reasons for Signed Waiver: Please select checkbox(es) that apply and sign at bottom.
Self Pay
- Select
Self Pay - I am not covered under a health insurance plan and/or choose not to utilize my health insurance plan. I choose to receive and to pay for the therapy services out of pocket.
No referral/Rx
- Select
No referral/Rx - I have presented to my appointment without proper referral or prescription from my referring physician. I understand that my carrier requires a prescription or referral as proof of medical necessity. If my carrier denies payment based on the lack of prescription or referral, I agree to pay for services rendered during the period of lapsed prescription/referral.
Pending Authorization
- Select
Pending Authorization - I am aware that my insurance coverage requires prior authorization. At this time, authorization will be or has been submitted however it is still pending and cannot be verified. If my carrier denies the authorization, I agree to pay for services rendered during the unauthorized date(s) of service.
Not Eligible/Out(Max) of Benefits
- Select
Not Eligible/Out(Max) of Benefits - I am aware that my insurance coverage is not eligible on this date(s) of service and / or I agree to pay for any services that exceed my plan limits. I understand POST will not file claims to my insurance during this period and network adjustments will not be applied. I choose to receive and to pay for the therapy services out of pocket.
3rd Party / Attorney Liens
- Select
3rd Party / Attorney Liens - I have been involved in an accident that resulted in my injuries and the responsible party will be reimbursing me for the services I receive as part of recovery or I have retained an Attorney to assist in my settlement. I understand that POST will not accept payment or deferred payment from either a 3rd Party and/or Attorney Lien. I agree to pay for all services related to this claim and I am ultimately responsible for the full payment of all services rendered.
Other
- Select
Description of Other
I understand and accept that I am financially responsible as checked above, for services rendered at POST.
Signer's Name*
First Last
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Patients

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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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

Agreement to Self Pay/Waiver for Insurance Exclusions

Agreement to Self Pay/Waiver for Insurance Exclusions

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