SURGICAL FINANCIAL WAIVER [Gynecomastia]

107 Newtown Rd, Ste 2A, Danbury, CT 06810

131 Kent Rd, New Milford, CT 06776

488 Main Ave, Norwalk, CT 06851

901 Ethan Allen Hwy, Ridgefield, CT 06877

1290 Summer St, Ste #4100, Stamford, CT 06905

SURGICAL FINANCIAL WAIVER

You need to make a choice about receiving these healthcare items or services.

Name of Patient:*

First NameLast Name

Patient's date of birth:*

Date

Your health insurance may not cover/pay for the services described below regardless of prior authorization being completed in advance. At times, they request documentation after the fact as to whether to cover the procedure or not.

PROCEDURE	ESTIMATED COST
Gynecomastia	$8,000 - $10,800

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.

Ask us to explain, if you don't understand why your insurance carrier probably won't pay.
Ask us how much these items or services will cost you (estimated cost is $8,000 - $10,800)

Please choose ONE option:*

1. YES, I want to receive these items or services. I understand that my insurance carrier may not decide whether to pay unless I receive these items or services. I understand that you may bill me for items or services and that I may have to pay the bill while my insurance is making its decision. If insurance denies payment, I agree to be personally and fully responsible for payment. That is, I will pay personally, out of pocket.2. NO, I have decided not to receive these items or services. I understand that you will not be able to submit a claim to my insurance and that I will not be able to appeal your opinion that my insurance may not pay.

Patient or Guardian signature*

Date

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.