Common Contracts
1 similar Pay Agreement contracts
SELF-PAY AGREEMENTPay Agreement • April 30th, 2013
because CIGNA Behavioral Health had determined the treatment does not meet CIGNA Behavioral Health’s standards for medical necessity. I am aware of CIGNA Behavioral Health’s formal clinical appeal process and have elected not to appeal this decision at this time. Instead, I have chosen to continue treatment with my provider/facility on a self-pay basis starting , which is no earlier than signature date. Date
