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. ELECTRONIC services select Signature of Individual or Individual's Legally Authorized Representative : *FirstMiddleLastDate Signed : *Submit
