KS-Opt Out Insurance Filing

Opt Out of Insurance Filing

You have opted to pay for the services outlined below in lieu of having them filed on a claim through your health insurance carrier. You are expected to pay for these services in full.
Child's Full Name*

First NameLast Name
Services:
I have read this policy and agree to pay for the services outlined above which I do not want filed on a claim through my health insurance carrier.
Signature of Parent or Guardian *
Date*

MonthDayYear
Date
Should be Empty: