Patient Health Insurance WaiverElection to Self-Pay for ServicesHolistic Health Associates is listed as a participating provider with my insurance company: Name of insurance company I understand that some or all of the services provided to me by Holistic Health Associates are listed as covered by my policy with my insurance company. I understand that by signing this document, no claim(s) will be sent to my insurances for my services at Holistic Health Associates. Until such time as I may otherwise advise Holistic Health Associates in writing, I elect to pay for all services rendered to me by Holistic Health Associates at their discounted self-pay rates. By election to self-pay for my services, I understand that any payments I make to Holistic Health Associates will not be credited towards satisfying any deductible(s) or out-of-pocket maximums I may be subject to under my health insurance plan. I have read this Election to Self-Pay for Services form in its entirety and have had the opportunity to ask any questions I may have had about the form, including payment options. Any questions I may have asked in regard to this form have been answered thoroughly. Despite my knowledge and understanding of the above, it is my personal decision not to use my health insurance benefits for my services at Holistic Health Associates (Elective Self Pay). By signing the document below, I acknowledge that I have read and fully understand this document in its entirety. I have had an opportunity to ask questions and am fully aware of what I am signing. Signature of Patient, Legal Representative, or Parent/Guardian(Required)Date(Required) Month Day Year Printed Name of Patient, Legal Representative, or Parent/Guardian(Required)Relationship to Patient(Required)
