2. I am covered by one of the Company’s health insurance plans.
3. The health plan under which I am covered includes benefits for some or all the services provided by the Clinic.
4. Despite the above, I do not wish the Clinic to submit a claim to the Company for the services provided to me by the Clinic.
5. Until such time as I may otherwise advise the Clinic in writing, I elect to pay for all services I receive from the Clinic at their MDteleMe | Rosabel M Bencomo’s discounted rates.
6. By election to self-pay for services, any payments I make to the Clinic will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with the Company unless it is otherwise permitted under the terms of my health plan.
7. 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.
8. Any questions I may have had about this form have been answered to my satisfaction.
9. I have freely chosen to self-pay for services after having asked the Clinic about payment options having carefully considered those options.