Acknowledgement of Self-Pay Status

Dear Patient,

You are being provided this letter of acknowledgement because you have requested that your doctor visit todaybecoded as “self-pay”. A self-pay option is offered to patients who elect to pay for the service in full onthedateofservice and who will not be submitting the claim to an insurance carrier. You have requested that this service be coded as self-pay because (initial one):

We want you to know what to expect so that you can make an informed decision. In order toaccomplish this, by signing below you agree to the following:

•  All fees for the self-pay service must be paid on the date of service.
• The self-pay amount covers only the professional services provided by your provider. You are financially responsible for all ancillary services, for example laboratory, prescription medication, imaging or other services not performed by your provider. You will receive a separate bill from those other providers for their services.
• Please let your provider or a staff member know where you prefer to have your lab work or imagingdone. We will gladly provide you the paperwork you will need to accomplish this.
• If you have insurance or other types of coverage, services received today that are included in the “self-pay”optionwill not likely be reimbursed by your carrier, or applied to your deductible. You may want to discuss thiswithyourinsurance carrier before agreeing to the self-pay option.

By my signature below, I acknowledge that I have read and understand the above and have been giventheopportunity to ask questions. I confirm that I am the patient, or the patient’s duly authorized representative.