PRIVATE PAY AGREEMENT

Thomas Park, M.D. & Associates
23077 Greenfield Rd. Suite 430
Southfield, MI 48075
Phone: (248) 552-0044
Fax: (248) 423-7777

Some clients decide to not use their insurance benefits for therapy and medication managent services. the following agreement outlines the terms of payment between clients who choose not to use insurance coverage and Thomas Park M.D. & Associates.

Please initial each item to indicate that you have read, understand, and agree with the following items:

Initials* I'm choosing not to use any Health Insurance Coverage to pay for therapy or medication management services with Thomas Park M.D. & Associates.

Initials* I understand that Thomas Park M.D. Associates will not bill any third party or insurance companies for any services or fees incurred while I am in treatment.

Initials* I understand that if I decide to use my insurance coverage, I will alert Thomas Park M.D. & Associates in writing, and that any treatment provided before that date will not be billed to my insurance.

Initials* I understand that Thomas Park M.D. & Associates may not be a provider with my insurance company.

Initials* I understand that I am solely responsible for any fees incurred while in treatment with Thomas Park M.D. & Associates.

Initials* I am aware of the fees per treatment session at Thomas Park M.D. & Associates.

Patient Print Full Name*

Patient Date of Birth *

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