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Selection for Self-Pay

I, the undersigned patient, acknowledge that I understand and agree that:

  1. Kat Devereaux, LPC with Phases Therapy, Inc (“Clinic”) is a participating provider with (“Company”)my insurance on file.
  2. I am covered by one of the Company health insurance plans.
  3. The health plan under which I am covered includes benefits for some or all of the services provided by Clinic
  4. Despite the above, I do not wish Clinic to submit a claim to Company for services provided to me by Clinic
  5. 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.
  6. By election to self-pay for services, any payments I make to Clinic will not be credited toward satisfyingany deductible I may be subject to under my health insurance plan with Company unless otherwisepermitted under the terms of my health plan.
  7. 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 been answered to my satisfaction
  8. I have freely chosen to self-pay for services after having asked Clinic about payment options andhaving carefully considered those options.