WCP Version: 1 Created: 1/04/2021
2. I continue to be insured under a health insurance plan offered with which (“Whole Child Pediatrics”) continues to participate.
3. By my signature below, I revoke my earlier election to "self-pay" for services and direct Whole Child Pediatrics to begin billing my health plan for services provided by Whole Child Pediatrics.
4. The health plan under which I/or my family am covered may limit coverage for services provided by Whole Child Pediatrics and/or may subject me to a deductible that must be satisfied before any benefits are provided under the health plan.
5. I will be personally responsible for the cost of any services provided to me/or my family by Whole Child Pediatrics that are not covered by my health plan to the extent consistent with the terms of my health plan.
6. Whole Child Pediatrics will bill for services at their contracted rates as a participating provider with your insurance, which may be higher than the discounted rate Whole Child Pediatrics makes available to patients who "self-pay" for services.
7. I have read this Revocation of Patient Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about this form. Any questions I may have had about this form have been answered to my satisfaction.
8. I am aware that once my claim(s) have processed I am financially responsible for all fees and there will be no additional adjustments made outside of what the insurance has allowed per the Provider contract.
9. I am aware that Whole Child Pediatrics will not rebill past visits for which I elected to not use insurance and the restrictions with prior authorizations, release of medical records and speaking with insurance for these visits still remains in place regardless of future visits.