A form to document a client’s choice to decline the use of insurance for services.
When clients choose to pay out-of-pocket instead of using commercial insurance or Medicaid, clear documentation is essential for transparency and compliance. This form helps you record the client’s informed decision to opt out of insurance billing and acknowledges that the service will not be submitted to their insurer.
Completing this form supports clinicians in maintaining accurate records, ensures clients understand their payment responsibilities, and helps prevent billing misunderstandings.
The file is provided as a non-fillable PDF, designed for printing and physical completion. It can be included in your intake packet, used at the start of treatment, or added to clinical documentation for ongoing reference.
A form to document a client’s choice to decline the use of insurance for services.
When clients choose to pay out-of-pocket instead of using commercial insurance or Medicaid, clear documentation is essential for transparency and compliance. This form helps you record the client’s informed decision to opt out of insurance billing and acknowledges that the service will not be submitted to their insurer.
Completing this form supports clinicians in maintaining accurate records, ensures clients understand their payment responsibilities, and helps prevent billing misunderstandings.
The file is provided as a non-fillable PDF, designed for printing and physical completion. It can be included in your intake packet, used at the start of treatment, or added to clinical documentation for ongoing reference.
