Waiver of Insurance Billing for Private Pay Clients

"Your Path To a Better You"

Yonkers, NY|connect@elysianintegrativehealth.com|914-512-8059|www.elysianintegrativehealth.com
Waiver of Insurance Billing for Private Pay Clients

Elysian Integrative Health and Wellness Group
I,
Name

First NameLast Name
have chosen to be a private pay client. This means that at the time of service I will be paying by cash, check, or credit card. Elysian Integrative Health and Wellness Group will not bill insurance for services pro vided under this arrangement. No forms will be produced now, or in the future, for you or us to submit for insurance billing.
I agree to:

1) Pay at the time of service, and

2) Waive insurance billing by Top Tier Health and Wellness Group

3) Notify Top Tier Health and Wellness Group of a desire to change this agreement prior to private payment for a session
Further, I attest that I do not have Medicaid for insurance purposes, as Federal law disallows Medicaid clients from paying out of pocket for these services.
Client name (please print):*
Client signature:*
Date*

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Date
Should be Empty: