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CHUSA Opt Out Form

PATIENT ELECTION TO SELF-PAY FOR SERVICES

the undersigned patient, acknowledge that I understand and agree that:

2. I am covered by one of the Company health insurance plans.

3. The health plan under which I am covered includes benefits for some or all of the services provided by Clinic.

4. Despite the above, I do not wish Clinic to submit a claim to Company for services provided to me by Clinic.

5. Until such time as I may otherwise advise Clinic in writing, I elect to pay for all services I receive from Clinic at their ChiroHealthUSA discounted rates.

6. By election to self-pay for services, any payments I make to Clinic will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with Company unless otherwise permitted under the terms of my health plan.

7. I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.

8. I have freely chosen to self-pay for services after having asked Clinic about payment options and having carefully considered those options.

    Patient:

    Thank you for taking the time to fill out this form.

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    Office Hours

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    Chiropractic Office Hours

    Monday:

    7:30 am-5:30 pm

    Tuesday:

    7:30 am-6:00 pm

    Wednesday:

    Closed

    Thursday:

    7:30 am-6:00 pm

    Friday:

    7:30 am-12:30 pm

    Saturday:

    Closed

    Sunday:

    Closed