PATIENT WAIVER FOR NON-COVERED SERVICES

PATIENT WAIVER FOR NON-COVERED SERVICES | DAY TREATMENT

Please review and acknowledge this waiver for non-covered Day Treatment services.
Patient’s Name
Your insurance may not cover (pay) for all your healthcare services. Some services are not considered “covered benefits” under your health insurance plan, and your insurance will not pay for these services.

Your provider believes that the following service(s), although not covered by your health insurance, are an important part of your care and recommends that you receive these services as part of your current treatment plan. However, since the services listed here may not be considered a covered benefit under your health insurance, should you choose to receive these services, you may be personally responsible for the payment of such services. The purpose of this notice is to help you make an informed choice about whether you want to receive these items or services.

The services recommended by your provider are listed below:

H2012 $50.00

The visit cost for the services/items recommended by your physician could vary in expense including any variation of the above amounts or combination of for each date of service on going for the month noted on this waiver.
I acknowledge that I have been informed in advance of receiving these services that these services may not be covered by my health insurance plan. I have chosen to receive these services and understand that I may be financially responsible for the charges indicated above.
Print Patient Name
Patient Signature (Please sign below to acknowledge and accept responsibility for payment of non-covered services.)
Name of Parent or Legal Guardian (if applicable)
Signature of Parent or Legal Guardian (if applicable)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This form must be signed by the patient or legal guardian PRIOR to receiving any non-covered services or items and must be maintained in the patient’s medical record.
Should be Empty:

PATIENT WAIVER FOR NON-COVERED SERVICES | DAY TREATMENT