SURGICAL FINANCIAL WAIVER
You need to make a choice about receiving these healthcare items or services.
We expect that your health insurance may not pay for the item(s) or service(s) that are desribed below.
The fact that your health insurance may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it. Right now, in your case, your insurnace carrier may not pay for:
The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay form them yourself. Before you make a decision about your options, you should read this entire notice carefully.
Note: Your health information will be kept conifdential. Any information that we collect about you on this form will be kept confidential in our office. If a claim is submitted to insurance, your health information on this form may be shared with the insurance carrier. That individual carrier will keep your health information, which the insurance carrier sees, confidential.