You are being provided this letter of acknowledgement because you have requested that your visit with Integrative Behavioral Health & Healing Practice today be coded as “self-pay” and that you receive a “self-pay discount.” A self-pay discount is offered to patients who elect to pay for the service either 1) in full on the date of service via credit card or 2) by check received prior to the date of service and who will not be submitting the claim to an insurance carrier. 

We want you to know what to expect so that you can make an informed decision. In order to accomplish this, by signing below you agree to the following:

• All fees for the self-pay service must be paid on or before the date of service.
• You must have a valid credit card on file with our billing department.
• Checks must be written for the amount pertaining to their appointment type (Follow up appointment forspecified amount of time, New patient appointment, Paperwork appointment).
• If payment is not received on or before the date of service, your current appointment may be cancelled,or you may be unable to schedule future appointments with your provider.
• The self-pay amount covers only the professional services provided by your provider. You are financially responsible for all ancillary services, for example laboratory, Genesight, or other services not performed by your provider.

By my signature below, I acknowledge that I have read and understand the above and have been given the opportunity to ask questions. I confirm that I am the patient, or the patient’s duly authorized representative.