I understand and agree that:
• I have voluntarily elected not to use my insurance for counseling sessions;
• My therapist did not encourage, initiate, coerce, persuade, imply, or otherwise cause me to opt out of my insurance, verbally or otherwise; this decision is my own for my own reasons;
• I am not opting out of using my insurance to gain a specific time slot or any auxiliary
benefits provided by my therapist implied or otherwise;
• My treatment was not threatened in any way by either signing (or not signing) this opt out form;
• Opting out of my insurance means that I must pay out-of-pocket for the counseling sessions;
• I have made my therapist aware that I am voluntarily decided to opt out of using my insurance for counseling sessions even if she is in-network or out-of-network;
• I will let my therapist know if anything changes, and I either obtain alternative insurance and/or decide that I would like my sessions billed to my insurance;
• If I opt of out using my insurance, I cannot use the payment of sessions towards my deductible and my therapist will not provide superbills for reimbursement purposes;
• I cannot opt out of services individually (i.e.., I want to opt out of insurance for video
sessions but not for in-person sessions) and that by opting out, I am opting out of entirely using my insurance for all services;
• If I elect to voluntarily use my insurance in the future, my therapist reserves the right not to allow me to opt out of using my insurance again;
• If I choose later to use my insurance, my therapist is not liable and is not obligated to reimburse previous sessions where I have chosen to opt out of billing my insurance; and
• If I choose later to use my insurance, my opting back into using insurance will start from the the day I notify my therapist of the change and cannot be backdated to previous sessions.
I acknowledge that I have been given the opportunity to ask questions and that Sentinel Mental Health has answered any and all of my questions.
Agreement. I have read, understood, and agree to the terms contained in the Insurance Opt Out
Agreement.