Private Pay Acknowledgement - TMHP Clients

For Patients Enrolled in 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 Medicaid on your behalf.

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

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