As of January 1, 2022, patients are entitled to notice, when your provider or facility isn’t in your health plan’s network, explaining the estimated cost of services, and what you may owe if you agree to be treated by this provider or facility.
If you and I have agreed not to use your health insurance but continue to meet, please provide your acknowledgment and consent using the online form. (see below). A PDF copy of the completed form will be emailed to you at the email address you provide in the form.
Please review the terms, then click the Consent box and the Send button to accept.
(I can send you a blank hard copy by mail or email or fax if you prefer.)