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Insurance Opt-Out Form

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ThoughtWell Counseling Services, LLC

Insurance Opt-Out Form

First and Last Name

Phone

Birthday

I have selected to not use my insurance for my counseling sessions.*

I understand that opting out of using my insurance means I must pay out of pocket for the counseling sessions.*

I have made my therapist aware that I have opted to not use my insurance for counseling sessions even if she/he is in network or out of network and understand these payments cannot be used towards my deductible*

I understand that if I choose to later use my insurance my therapist is not liable and is not obligated to reimburse previous sessions where I have chosen to opt out of billing my insurance. My opt in to use insurance will start from the day I notify my therapist of the change and cannot be backdated to previous sessions.*

By typing my name in the field below, I am acknowledging that I am voluntarily opting out of using insurance for therapy services and my therapist did not encourage or advocate for me to make this decision.

Date

ThoughtWell Counseling Services

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Insurance Opt-Out Form

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ThoughtWell Counseling Services, LLC

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