Insurance Opt-Out Form

If you have insurance and are opting not to use your insurance policy towards your therapy services, ThoughtWell Counseling Services requires completion of our Insurance Opt-Out Form.

You should only copmlete this form if you are voluntarily choosing not to use your insurance policy for therapy.

If you have any questions, please reach out to us before you submit the form.

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

Insurance Opt-Out Form

ThoughtWell Counseling Services, LLC

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