Self-Pay Waiver

Vail Physical Therapy

Self-Pay Waiver

I have requested services and/or therapies provided by a medical provider of Vail Physical Therapy. I understand that these services and/or therapies will be charged by Vail Physical Therapy. I further understand I am responsible for all charges incurred today for Evaluation and Treatment.

I am electing not to use my health insurance benefits for the above service/therapy, even though I understand that these services/therapies may be considered covered by my policy.

No claim will be sent to my insurance now or in the future, since it is my personal decision to self-pay.

PATIENT SELF-PAY WAIVER

I understand that I will pay for the physical therapy evaluation and treatment at time of service.

First

Last

Full Name (Electronic Signature) of Patient or Guardian

Date