Patient Waiver and Agreement for Self Payment - Leaps and Bounds Pediatric Therapy

Patient Name(Required)

First Last

Date of Service(Required)

Patient Waiver and Agreement For Payment

You have chosen to self-pay for health care services provided by Leaps And Bounds Therapy, LLC. You have decided to self-pay even though you may have health insurance and waive your right to have a claim submitted to your insurance company on your behalf. Your signature below indicated that you have received a copy of this document and are aware that you are waiving your right to have a claim submitted to your insurance company. Payments are due in full within one week of receipt of invoice which will be emailed to you unless otherwise indicated.

I authorize Leaps and Bounds Therapy to email my statements and other therapy information to me and acknowledge that this is via non-secure email.(Required)

Email(Required)

Signature:(Required)

First Last

Child's Name(Required)

First Last

Date(Required)