Opt Out Insurance - becalm-counseling

Becalm Counseling and Sobriety Support

Opt-Out Insurance Form

Opt-Out of Insurance

I have selected to not use my insurance for my counseling sessions.(Required)

I understand that opting out of using my insurance means I must pay out of pocket for the counseling sessions. I am eligible for the sliding fee scale if I choose to opt out.(Required)

I have agreed to let my therapist know if anything changes and I either obtain alternative insurance or decide that I would like my sessions billed to my insurance.(Required)

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.(Required)

Signature

Client Signature:

Date:

Therapist Signature:

Date:

Opt-Out Insurance

Becalm Counseling and Sobriety Support

Opt-Out Insurance Form

Opt-Out of Insurance

Signature

Quick Links

Contact Us