Self-Pay Acknowledgement / Insurance Waiver Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Patient's Name *FirstMiddleLastToday's Date *The following is an acknowledgement form between you and PSOT, which outlines your rights and responsibilities as a Self-Pay patient. I will be paying services directly because: (Please select one) *My insurance is not in-network with my provider at PSOT. As such, I have chosen waive my existing medical coverage for this service.I elect to waive insurance and be Self-Pay patient for personal reasonsI currently do not have insurance coverage and I am financially responsible for all services rendered.The service I will be receiving is not covered by my insurance, or the proper authorization has not been obtained or deniedNext * I understand that PSOT is accepting me as a private pay patient for the period of time until I rescind this wavier, and I will be responsible for paying for any services that I receive. The provider will not file a claim to Medicaid for the services that are provided to me If I am electing to Waive Insurance, I understand that PSOT will not submit claims to my health insurance carrier and that I am financially responsible for the charges associated with all services I receive. * I acknowledge I must prepay for my appointment 48 hours or 2 days before my next appointment or my appointment will be cancelled and I will have to call and reschedule my next appointment. If my appointment is cancelled, or I miss my appointment no medications will be ordered until I am seen. * After two no show appointments in one year, you will be subject to discharge from PSOT. There is a $65 no-show charge for missed appointments There is a $35.00 fee for all returned checks and for stop payments. ELECTRONIC SIGNATURE AGREEMENT: * I AGREE By selecting the “I agree” button, I am signing this document electronically. I agree that my electronic signature(s) is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature(s) on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor.Signature of Individual or Individual's Legally Authorized Representative : *FirstMiddleLastDate Signed : *Submit
