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.
• If you are utilizing a ministry sharing plan you will be required to provide a valid card on the date of service and at the time of service for verification services.
• The "self-pay" amount covers only the professional services provided by our office. You are financially responsible for all ancillary services, for example laboratory, x-ray or other services not performed by our office. You will receive a separate bill from those third-party facilities.
• 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 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.
• We are unable to provide medical records or speak to your insurance, if you have any, regarding any medical issues or help you in getting any medical necessity items approved 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 ARE A PATIENT WITH A MINISTRY SHARING PLAN NOTHING CHANGES FOR YOU AND YOU WILL STILL RECEIVE YOUR ITEMIZED BILL TO BE ABLE TO SUBMIT*