I,   First Name*   Last Name*, the undersigned patient (parent or legal guardian if Patient is a minor) (collectively the "Patient"), acknowledge, understand and agree that:

1. Therapy Care, Ltd. ("Therapy Care") may or may not be a participating provider with Insurance Company Name* ("Company").
2. Patient is covered by one of the Company’s health insurance plans.
3. The health plan under which Patient is covered includes benefits for some or all of the services provided by Therapy Care.
4. Despite the above, I do not wish Therapy Care to submit a claim to Company for all or a portion of the services provided to Patient by Therapy Care.
5. Until such time as Patient may otherwise advise Therapy Care in writing, Patient elects to directly pay Therapy Care for all, or a portion, of the services which Therapy Care provides to Patient.
6. By Patient’s election to directly pay Therapy Care for services (self-pay), any payments Patient makes to Therapy Care will not be credited toward satisfying any deductible Patient may be subject to under Patient’s health insurance plan with Company unless otherwise permitted under the terms of Patient’s health plan.
7. Patient has read this Patient Election to Self-Pay for Services form and has had the opportunity to ask any questions Patient may have had about the form. Any questions Patient may have had about this form have been answered to Patient’s understanding and agreement.
8. Patient acknowledges that they have freely chosen to self-pay for services after having asked Therapy Care about payment options and having carefully considered those options.