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Self Pay Waiver

Self Pay Waiver


You are being provided this waiver because you have requested that your doctor visit 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 services received in full on the date of service and who are not submitting the claim to an insurance carrier. You have elected to self-pay for today?s services because (select one):


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 are agreeing to the following:


? All fees for self-pay are to be paid on the date services are rendered.

? The self-pay amount covers only the services provided by the physician and does not cover costs incurred for any ancillary services such as labs, testing or any additional care that may become necessary if circumstances suggest any variations from normal during the physician?s assessment. You will receive a separate bill from the M. T. Curry Pediatrics billing department for those non-covered services.

? If you have insurance or other types of coverage, services received today that are included in the ?self-pay? discount will not likely be reimbursed by your carrier or applied to your deductible. You may want to discuss this with your insurance carrier before agreeing to be self-pay.

? If you obtain retroactive insurance after you have self-paid it will be your responsibility to file any pre-existing claim with said insurance company and you are not eligible for reimbursement through M. T. Curry Pediatrics for any payments made.


By signing below, you acknowledge that you have read and understand the above and have been given the opportunity to ask questions.

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