Balance Waiver Request Form
Client's Name
First Name
Last Name
Client's DOB
-
Month
-
Day
Year
Date
Client's E-mail
example@example.com
Client's Phone Number
-
Area Code
Phone Number
Therapist Full Name
Insurance Name (Enter 'N/A' if not applicable to your client)
Co-Pay (If applicable)
Date of Balance: Please add an additional field for each date where a balance is being requested.
*
Total Balance Amount
*
(Amount requested to be waived)
Additional Instructions/Notes
Submit
Should be Empty: