Alabama Private Pay Acknowledgement

For Patients Enrolled in Alabama Medicaid:

Mi-Kyle Health not a Medicaid-enrolled provider.

You are being accepted as a private pay patient and are responsible for paying the fees for all services received. We are a fee for service practice. This means that payment is due at the time services are rendered.

Our services, which may otherwise be covered by Medicaid if provided by a Medicaid-enrolled provider, are not covered if provided by us. Should you wish for your services to be covered and reimbursed by Medicaid, you must obtain services from a Medicaid-enrolled provider.

By signing this Client Acknowledgement Statement, you acknowledge that you understand that you are being accepted as a private pay patient, that you are responsible for paying all fees charged for our services, and that no claims will be filed with Alabama Medicaid on your behalf.

Cancellation: As a courtesy to others and our providers, we require a 24-hour cancellation notice if you cannot attend your appointment. We may place reminder calls on the day prior to your appointment, but it is always your responsibility to remember the time and day of your appointment. If we do not receive the notification to cancel over 24 hours from the appointment, you will be charged in full. If you are more than 15 minutes late to your appointment, you may be required to reschedule the appointment and pay for the missed appointment. By signing below, you agree that we may charge the cancellation fee to the credit card account on file with us.

By signing this form you indicate that you have read and understand the above written statements.

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