Insurance Waiver

Insurance Waiver
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Name of Provider at DHWC (if unsure or unknown, enter "NA")*
Declaration of Waiver
I am choosing to waive my right to use my health insurance(s) for services provided at Diversified Health and Wellness Center, LLC and/or Diversified Health and Wellness Cares, LLC (collectively "the Companies"). Under any circumstance, I shall not hold the Companies liable for any financial matters or obligations incurred which may relate to this waiver.

Client or Parent/Legal Guardian Signature: Signature*
Date: Date*
Clinical Director Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Declaration of Waiver