I, {patientName}, hereby declare and affirm the following statements:
Attempt to Use In-Network Provider: I attempted to seek medical services f rom an in-network provider covered by my health insurance for the treatment of injuries sustained in an accident.
Refusal by In-Network Provider: The in-network provider refused to provide me with specialist services upon learning of my involvement in an accident.
Details of In-Network Provider Refusal:
In-Network Provider's Name: ____________________
Date of Refusal: _________________
Reason Given for Refusal: Stated policy or reason for not providing services to patients involved in accidents.
Impact on Access to Care: This refusal has impeded my ability to receive necessary medical care in a timely and efficient manner, as recommended by medical professionals.
Seeking Alternative Care: Due to this refusal, I am now compelled to seek medical care outside of my health insurance network, which may incur additional personal expenses and logistical challenges.
Acknowledgment and Understanding: I acknowledge the situation and understand the need to explore alternative options for my medical care and treatment.
I affirm that the information provided in this affidavit is true and correct to the best of my knowledge and belief.