- I understand that my health plan (Tricare and other plans) may impose a limit on balance billing by out of
network providers. I wish to waive any limit on balance billing and receive treatment from this out of network
- I understand that I am seeking the care of PDAA for a service that may not be covered by my insurance
company. I understand that my insurance plan may not cover any part of the charges, costs or expenses
related to Anesthesia services and I will be responsible for all charges incurred.
Date: September 20, 2021