WCP - ACKNOWLEDGMENT OF SELF–PAY STATUS PATIENT RESPONSIBILITY

ACKNOWLEDGMENT OF SELF–PAY STATUS PATIENT RESPONSIBILITY

WCP
Version: 3
Created: 03/25/2022
You are being provided this letter of acknowledgement because you have requested that your office 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 service in full on the date of service and who will not be submitting the claim to an insurance carrier.
Patient Name Patient Name First Last
Patient DOB Patient DOB / MM / DD YYYY
Email
Phone Phone - ### - ### ####
You have requested that services be coded as "self-pay" because :

You have requested that services be coded as "self-pay" because : 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.
You are requesting the following

You are requesting the following All dates of service moving forward be treated as "self-pay".
Starting with date of service Starting with date of service / MM / DD YYYY
We want you to know what to expect so 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 in full on the date of service and at time of service.

• You also understand that we are a Pediatric medical facility and a medical home. If your family consists of more than one minor child, we require that all minor children be seen at our facility.

• If you did not pay for a service at the time it was provided you agree, and are aware, that we will charge your card on file for the said service amount, and you will not receive a statement prior to your card being charged.

• You will not be able to make additional appointments for yourself or family members unless you have a zero balance on the account.

• The "self-pay" amount covers only the professional services provided by our office. .

• Please know, if you have insurance and choose to not use it, ancillary services and prescriptions may not be covered by your insurance company if they are a result of the visit today. *Please Note: It will be your responsibility to obtain your test results and provide the results to our office*

• 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. This office will not provide any documentation such as procedure codes, diagnosis codes, CMS 1500/HCFA or UB-04 forms associated with the visit that could be used to submit to your insurance for reimbursement.

• We are unable to provide you with any necessary prior authorizations that may be needed by your insurance, if you have any, that may be needed for prescription coverage or any other medical needs such as therapies or medical imaging.

• We are unable to provide medical records, communicate in writing or speak to your ministry sharing plan or insurance, if you have any, regarding any billing, medical issues or help you in getting any medical necessity items approved while you are a “self-pay” patient.

• Our office is unable to coordinate care for you while you are a "self-pay" patient.

• Once you have been seen as a “self-pay" patient for a visit that visit remains as a “self-pay” visit and our office will not submit it to any other insurance plan down the road.

• If you require receipts you will need to request these on a monthly basis in order to receive them as our staff will not process requests for multiple dates of service stemming from more than a 30 day span.

• *IF YOU ARE A PATIENT WITH A MINISTRY SHARING PLAN YOU WILL NOT RECEIVE ITEMIZED BILLS (showing CPT codes; we will not provide a CMS-1500/HCFA or UB-04 form nor will our office complete one or submit one on your behalf).*
By my signature below, I acknowledge that I have read and understand the above and have been given the opportunity to ask questions and they have been answered to my satisfaction. I confirm that I am the patient, or the patient’s duly authorized representative.

Draw or Type

I understand this is a legal representation of my signature.

The eSIGN act of 2000 established the legal basis for the use of electronic signatures in the United States as an alternative to paper signatures. By completing this form your signature or mark will be legally binding. Clear

Full Name

I understand this is a legal representation of my signature.

The eSIGN act of 2000 established the legal basis for the use of electronic signatures in the United States as an alternative to paper signatures. By completing this form your signature or mark will be legally binding.
Date of Signature Date of Signature / MM / DD YYYY
Patient (if 18 or older) or Representative Name (if minor) Patient (if 18 or older) or Representative Name (if minor) First Last
If signed by someone other than the patient, please specify relationship to the patient:
-NOT PART OF THE LEGAL MEDICAL RECORD-

WCP - ACKNOWLEDGMENT OF SELF–PAY STATUS PATIENT RESPONSIBILITY

WCP - ACKNOWLEDGMENT OF SELF–PAY STATUS PATIENT RESPONSIBILITY

ACKNOWLEDGMENT OF SELF–PAY STATUS PATIENT RESPONSIBILITY

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

-NOT PART OF THE LEGAL MEDICAL RECORD-