PATIENT ELECTION TO SELF-PAY FOR SERVICES
I, _____________________________________________________, the undersigned patient, acknowledge that I understand and agree that:
*
First Name
Last Name
YourTime Psychiatry and Medical Cannabis LLC (
"Clinic"
) is a participating provider with
Insurance Company
*
(
"Insurance Company"
).
I am covered by one of the
Insurance Company
health insurance plans.
The health plan under which I am covered includes benefits for some or all of the services provided by
Clinic
.
Despite the above, I do not wish
Clinic
to submit a claim to
Insurance Company
for services provided to me by
Clinic
.
Until such time as I may otherwise advise
Clinic
in writing, I elect to pay for all services I receive from
Clinic
at their self-pay rates.
By election to self-pay for services, any payments I make to
Clinic
will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with
Company
unless otherwise permitted under the terms of my health plan.
I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.
I have freely chosen to self-pay for services after having asked
Clinic
about payment options and having carefully considered those options.
Date:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient:
*
Printed Name of Patient or Responsible Party
*
Capacity of Responsible Party (e.g. parent, guardian, etc.)
*
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