wsfmed.com - Self-Pay Agreement

Self-Pay Agreement

Complete this before your appointment and your provider can be better prepared during their time with you.
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Date of Birth

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The following is a statement of our Self-Pay Agreement which we require that you read and sign prior to receiving treatment.

I understand that I will be responsible for all charges related to my care at Pavilion Family Medicine.

I understand that charges presented to me are to be paid in full at the time of service, unless arrangements have been made in advance with the Practice Manager. I also understand that these charges are solely related to services provided by the physician and nurse practitioner and/or other services that are performed in the office.

I understand that there may be additional charges for any procedures performed at my office visit. If any procedures are performed, I will receive a bill which must be paid prior to or at my next office visit.

I have read and fully understand the Self-Pay Agreement outlined above. In the event it is necessary to turn my account over to a collection agency, I have been made completely aware that I am responsible for any and all additional costs and fees associated with the collection process.
My signature below acknowledges receipt of the Self-Pay Agreement and Self-Pay Fee Schedule
Patient/Legal Guardian Name
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Date

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Date
Please review to ensure the details are correct before completion.
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