M.T. Curry Inc - Publicforms

Available Forms

12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

Self Pay Waiver

Patient Name *

Patient Date of Birth *

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):

Reason for Self Pay *

You have no health insurance.

You have health insurance, but you do not want your insurance billed and instead want to pay out of pocket.

Other (please explain below)

Other Reason for Self Pay

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.

I agree. *

I confirm that I am the patient, or the legal guardian/guarantor for the patient. *

Parent or Guardian Signature *

Today's Date *

* Required field