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.