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Agreement to Self Pay/Waiver for Insurance Exclusions

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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.

Leave this empty:

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Signed by POST PT Luke Ferdinands
Signed On: November 24, 2020


Signature Certificate
Document name: Agreement to Self Pay/Waiver for Insurance Exclusions
lock iconUnique Document ID: ed4c481a9acc459cb94b2baaaa0ce32805dc7d62
Timestamp Audit
October 27, 2020 2:42 pm ESTAgreement to Self Pay/Waiver for Insurance Exclusions Uploaded by POST PT Luke Ferdinands - info@postpt.com IP 108.7.177.191