I, {patientName}, hereby declare and affirm the following statements: Intention to Use Health Insurance: It was my intention to use my health insurance for seeking a surgical consultation or intervention necessary for my health condition.

Involvement in Automobile Accident: I was involved in an automobile accident, which necessitated medical attention beyond general care.

Refusal by Primary Care Physician: My Primary Care Physician (PCP), My PCP refused to schedule me for an appointment due to my involvement in the aforementioned automobile accident.

Impediment in Obtaining Specialist Referral: Due to my PCP's refusal to see me, I have been unable to obtain a necessary referral to a medical specialist. This referral is a prerequisite by my health insurance for any specialized surgical consultation or intervention.

Impact on Health and Treatment: This inability to secure an appointment with my PCP and consequently a specialist referral has significantly delayed my access to essential medical care. It has prolonged my discomfort and potentially exacerbated my medical condition.

Acknowledgment and Understanding: I understand the gravity of this situation and am actively seeking alternative avenues to address my medical needs in light of my PCP's refusal to provide care to activate my health insurance benefits. I fully understand that by choosing not to utilize my health insurance, I will be personally responsible for all costs associated with the procedure. I acknowledge that these costs may be significantly higher than those typically covered by insurance.

I affirm that the information provided in this affidavit is true and correct to the best of my knowledge and belief.