BlueStone Psychotherapy

Insurance Opt Out


Opt-out Request


I, the undersigned, hereby request to opt out of the insurance coverage for the following reason(s):


Acknowledgment and Agreement

I understand that by opting out of the insurance coverage provided by BlueStone Psychotherapy, I will not be eligible for the benefits and coverage offered by the plan. I acknowledge that my decision is voluntary and that I have been provided with information about the insurance plan options available to me.


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Signature Certificate
Document name: Insurance Opt Out
lock iconUnique Document ID: 538c6b40dcdcfe8ac96b71e3cd12ff82692fbbcb
Timestamp Audit
March 18, 2024 9:59 am EDTInsurance Opt Out Uploaded by BlueStone Psychotherapy, PLLC - IP