Waiver of Medicaid Coverage for Mental Health Care

Release of Information: Drug and Alcohol Use Information and Records

I hereby acknowledge that I have been informed that Dr. Ronit Levy and Bucks County Anxiety Center are not credentialed Medicaid providers. As a result, I will not be able to use my Medicaid benefits and I will not be able to submit receipts for reimbursements. I will have to pay for each session completely out of pocket at the time of the session. I have also been informed that should I choose to use my Medicaid benefits, I will need to terminate treatment with my therapist and any connection to Bucks County Anxiety Center in order to see a Medicaid provider at another practice.