Spencer Psychology

Waiver of Insurance

I understand that I might have insurance that could be used for services elsewhere, but am electing to waive my insurance benefits for the duration of treatment with providers at Spencer Psychology. I understand that there may be other providers in the community who could provide services at a lesser cost or no cost to me.

I understand this means Spencer Psychology will not be billing my insurance. If I choose to file on my own, I understand that I may not receive any reimbursement from my insurance due to these or other reasons:

Client Name:  

Electronic Signature of Client/Parent/Guardian:  

Date: