I, the undersigned patient, acknowledge that I
understand and agree that:
- Kat Devereaux, LPC with Phases Therapy, Inc (“Clinic”) is a participating provider with (“Company”)my insurance on file.
- I am covered by one of the Company health insurance plans.
- The health plan under which I am covered includes benefits for some or all of the services provided by Clinic
- Despite the above, I do not wish Clinic to submit a claim to Company for services provided to me by Clinic
- Until such time as I may otherwise advise Clinic in writing, I elect to pay for all services I receivef rom Clinic at the Clinic’s standard rates.
- By election to self-pay for services, any payments I make to Clinic will not be credited towardsatisfying any deductible I may be subject to under my health insurance plan with Company unlessotherwise permitted under the terms of my health plan.
- I have read this Election to Self-Pay for Services form and have had the opportunity to ask anyquestions I may have had about the form. Any questions I may have had about this form have beenanswered to my satisfaction
- I have freely chosen to self-pay for services after having asked Clinic about payment options andhaving carefully considered those options.