CONSENT TO OPT OUT OF INSURANCE BILLING

 

The purpose of this form is to provide consent to Jacob Slagle, MS, LMFT and TheEasyTherapy.com ("The Practitioner") to provide psychotherapy services to you and your family member (Both You and your Family Member(s) are "The Client") without submitting billing to your current health insurance(s).

 

It is important, as The Client, that you understand the following:

-That opting out of insurance billing means that your payments to The Practitioner will not count toward your Out-of-Pocket nor will it count toward your Deductible or Health Savings Account.

 

-You, The Client, are consenting to opting out of insurance billing of your own free will and volition, with no pressuring and under no duress from The Practitioner.

 

-You, The Client, will be responsible for any financial liabilities for The Practitioner of The Client resulting from opting out of insurance. The Practitioner reserves the right to bill you for any financial liabilities resulting from you, The Client, engaging in exploitive financial behaviors. If you receive checks from insurance or report the sessions to your insurance or Healthcare Savings Account or other entities, you need to know that this behavior can create a financial and privacy liability for you when opting out of insurance reporting. You are consenting to pay any fees, fines, or associated debts that engaging in these exploitive behaviors may incur, and you agree to not engage in these behaviors by signing this form for you or your family member, and agree to release The Practitioner from all financial liabilities.

 

-The reasons for people to consent to opting out of insurance reporting are numerous, and may be due to out-of-network status of The Practitioner, or you may want more privacy for your file, or payments to your provider may have been denied and you want to keep your provider. This is not an all-inclusive list of reasons.

 

-This consent is revokable by submitting notice to The Practitioner, in writing, dated and signed.