Self Pay Dont Use Insurance Form

We offer an economical self pay program for families and individuals without insurance or with insurance we do not accept.

Self pay dont use insurance form. By election to self pay for services any payments i make to will not be creditedclinic toward satisfying any deductible i may be subject to under my health insurance plan with company unless otherwise permitted under the terms of my health plan. You have no health insurance. Bill insurance do not bill insurance elective self pay no claim will be sent to my insurance since it is my personal decision not to use my health insurance benefits for the above service therapy even though i understand that these services therapies are considered covered by my policy. By signing the election to self pay the patient is stating that they have chosen to opt out of their insurance and by doing so you will not be filing a claim with their insurance company and if the patient were to file a claim on their own there is no guarantee it will apply towards their deductible since the patient chose not to use their insurance.

You have requested that this service be coded as self pay because initial one. Non participating insurance accounts the financial obligations of patients who are insured by carriers with which the practice does not participate in are considered a self pay account. I have read this election to self pay for services form and have had the opportunity to ask. Also below is a revocation of self pay in the event the patient meets their deductible and would like you to begin using their insurance.

Also below is a revocation of self pay in the event the patient meets their deductible and would like you to begin using their insurance. You have health insurance but you do not want your. The hitech act hipaa expanded a patient s rights when it comes to whether to use their insurance or not but the law does state they can opt out of using their insurance if they pay the provider in full. To view the self pay prices for office visit charges and add on services select your state.

The conversation with the patient goes like this. Individual rights are expanded in important ways. Patients can ask for a copy of their electronic medical record in an electronic form. The undersigned agrees that i am individually obligated to pay the full charges at the time of service.

If a patient elects to opt out of their insurance you should have them sign an election to self pay form located below.