Balance Waiver Request Form

Balance Waiver Request Form
Client's Name

First NameLast Name
Client's DOB

MonthDayYear
Date
Client's E-mail
example@example.com
Client's Phone Number

Area CodePhone Number
Therapist Full Name
Insurance Name (Enter 'N/A' if not applicable to your client)
Co-Pay (If applicable)
Balance Amount
(Amount requested to be waived)
Reason for requesting a balance waiver
Additional Instructions/Notes
Should be Empty: