Waiver of Insurance Billing for Private Pay Clients

The following document serves as a formal agreement whereby private pay clients of Elysian Integrative 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.

IMPORTANT MESSAGE: If this is a medical or mental health emergency or if your life or someone else's is in imminent danger, please call 911 or go to the nearest emergency room (ER). If you are in a mental health crisis and need immediate support, call 988 to reach the National Suicide and Crisis Lifeline.