Dr. David DeFries
Below is an insurance opt out notification which will be presented during the first visit.
I, ( NAME) the undersigned patient,acknowledge that I understand and agree that:
1: Dr. David DeFries is a participating provider with Highmark, Independence, Independence Administrators, Amerihealth insurance plans.
2. I may be covered by one of the Company health insurance plans.
3. The health plan under which I am covered may include benefits for some or all of the services provided by Dr. David DeFries
4. Despite the above, I do not wish Dr. David DeFries to submit a claim to Company for services provided to me by Dr. David DeFries.
5. Until such time as I may otherwise advise Dr. David DeFries in writing, I elect to pay for all services I receive from Dr. David DeFries.
6. By election to self-pay for services, any payments I make to Dr. David DeFries will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with unless otherwise permitted under the terms of my health plan.
7. I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.
8. I have freely chosen to self-pay for services after having asked Dr. David DeFries about payment options and having carefully considered those options.