Deborah L. Radzwill, Psy.D.
Waiver of In-network Insurance Benefits
Services: ____ Individual Therapy Services
____ Couples Therapy Services
____ Family Therapy Services
____ Group Counseling Services
I have voluntarily chosen to seek mental health services from Dr. Deborah Radzwill, Licensed
Psychologist, effective on the date of ________________________. Dr. Deborah Radzwill
has explained to me that my insurer/managed care company (check all that apply):
_____Has a contract with her, however:
a) I have chosen not to utilize my insurance coverage; or
b) The services I have chosen are not covered under the contract;
c) The services I have chosen are not a covered benefit under my
insurance policy and I understand that Dr. Deborah Radzwill will not
be appealing the denial for authorization for such uncovered services.
_____Has not approved continued care as of the above effective date but I
have chosen to continue care with Dr. Deborah Radzwill.
_____ Has informed Dr. Deborah Radzwill that my benefit has expired during
treatment but I have chosen to continue care with Dr. Deborah Radzwill.
By obtaining the aforementioned services, I understand that my insurer/managed care
company will not reimburse Dr. Deborah Radzwill and that I assume full financial
responsibility for charges for services rendered. I also understand that I am free to pursue
appeals with my own insurance carrier.
Print Name of Patient or Legal Guardian Print Name of Subscriber if different from
(If Patient is a Minor) Patient
Signature of Patient or Legal Guardian Signature of Subscriber
Date Signed Date Signed
Dr. Deborah Radzwill