Patient Face Sheet - Women To Women printable pdf download

Patient Face Sheet - Women To Women

3 MARINA ROAD

YARMOUTH, ME 04096

PH: (207) 846-6163

FX: (207) 846-6167

Telephone Consultation Waiver -

Request to Opt Out of Using Contracted Insurance

Patient Name: _______________________________________

Patient’s Date of Birth: ________________________________

NOTE: If you opt out of using your insurance for a specific service or for all services on a specific date,

insurance will not and cannot be billed for these services at any later date.

Date of Telephone Consultation for which you will not use any insurance benefits: ______________

Amount due for service: ______________________________________________________

WHAT OPTING OUT OF USING YOUR INSURANCE MEANS:

Your insurance will not be billed for the service indicated above, nor may you bill your insurance

yourself.

The medical records related to the service indicated above will not be released to any third party

unless you sign a release authorization or if required by law.

You are required to pay in full for the service.

Please ask any questions you have about this process before signing below.

Signing below means you have read this notice and will not use your insurance benefits for

payment for this service. You agree to be financially responsible for the full cost of the service.

Signature: ___________________________________________

Date: ___________________

Please return this form to Women to Women

Mail: Women to Women, 3 Marina Road, Yarmouth, ME 04096

Email:

Fax:

(207) 846-6167

---------------------------------------- For office use only: Date Received: ___________________________

12/07

Patient Face Sheet - Women To Women