I, the undersigned client, acknowledge that I understand and agree that:
                                                     
A New Hope Therapy Center is a participating provider with my insurance carrier.

Despite the above, I do not wish A New Hope Therapy Center to submit a claim to my insurance company for services provided to me by A New Hope Therapy Center.

Until such time as I may otherwise advise A New Hope Therapy Center in writing, I elect to pay for all services I receive from A New Hope Therapy Center at their out of pocket rate.

By election to self-pay for services, any payments I make to A New Hope Therapy Center will not be credited toward satisfying any deductible I may be subject to under my health insurance plan unless otherwise permitted under the terms of my health plan.

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.

I have freely chosen to self-pay for services after having asked A New Hope Therapy Center about payment options and having carefully considered those options.