Patient Name(Required)
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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.
Signature:(Required)
Child's Name(Required)
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