A form that will be utilized for patients that want to opt out of utilizing their insurance benefits either in network or out of network. CAN NOT BE USED FOR MANDATORY BILLERS: FEDERAL, ASH, OR OPTUM HEALTH.
Revision 1/2025
A form that will be utilized for patients that want to opt out of utilizing their insurance benefits either in network or out of network. CAN NOT BE USED FOR MANDATORY BILLERS: FEDERAL, ASH, OR OPTUM HEALTH.
Revision 1/2025
