You are being provided this letter of acknowledgment because you have requested that your
provider visits be coded as “self-pay." This self-pay option is offered to patients who elect to pay
for the service in full on the date of service and who will not be submitting the claim to an
We want you to know what to expect so that you can make an informed decision. In order to
accomplish 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, lab work, urine
drug screens, or other services performed in Office. No prescriptions are included.
- Despite the outcome of your visit, you will not be reimbursed for our services.
- Please let your provider or a staff member know if you prefer to have your lab work
done somewhere else. We will gladly provide you with the paperwork you will need to
accomplish this. **Please Note: If you choose to use another facility, it will be your
responsibility to obtain your test results and provide the results to your provider**
- If you have insurance or other types of coverage, services received today that are
included as “self-pay” will not likely be reimbursed by your carrier, or applied to your
deductible. You may want to discuss this with your insurance carrier before agreeing to
By my signature below, I acknowledge that I have read and understood the above and have
been given the opportunity to ask questions. I confirm that I am the patient or the patient’s
duly authorized representative.