I {patientName},hereby declare and affirm the following
Acknowledgment of Recommended Procedure: I have been recommended by my healthcare provider to undergo a medical procedure deemed necessary for my health and well-being.
Decision to Forego Health Insurance: After careful consideration, I have decided to forego the use of my health insurance to cover the costs of the recommended medical procedure.
Reason for Decision - Financial Hardship: The primary reason for this decision is the significant out-of-pocket expenses associated with my health insurance plan. These expenses, including high deductibles, co-pays, and potential coinsurance, present a financial hardship that I am currently unable to bear.
Understanding of Financial Implications: 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.
Voluntary Decision: This decision has been made voluntarily, without any coercion or undue influence. I have been given ample opportunity to consider my options and seek advice as needed.
Release of Liability: I hereby release my healthcare provider and their affiliates from any liability or claim associated with my decision to not utilize health insurance for the payment of my medical procedure.
I affirm that the information provided in this affidavit is true and correct to the best of my knowledge and belief.