This professionally written Insurance Opt-Out Agreement allows private practices to document a client’s choice to decline use of insurance benefits and pay out-of-pocket for services.
Designed for mental health and behavioral health providers, this form clearly outlines that the provider will not submit claims, back-bill insurance, or issue superbills for reimbursement. It helps protect both parties by maintaining transparent, signed acknowledgment that services are self-pay only and not billable to insurance under any circumstance.
Includes:
Client and provider acknowledgment section
CPT code and session rate table
Signature fields and effective date range
Provider disclaimer and HIPAA-compliant footer
Editable PDF format
Best for:
Therapists, counselors, psychologists, and group practices needing a clear opt-out record for clients choosing private-pay services.