Waiver of Insurance Billing for Private Pay Clients
The following document serves as a formal agreement whereby private pay clients of Top Tier Health and Wellness Group choose to forgo insurance billing and opt to pay for services out-of-pocket via cash, check, or credit card. By signing this waiver, clients acknowledge their responsibility to make payments at the time of service and agree not to request insurance submissions now or in the future for these sessions. Additionally, clients confirm they do not have Medicaid, as federal regulations prohibit Medicaid recipients from paying out-of-pocket for these services. This agreement ensures clarity regarding billing practices and client responsibilities.
