Self Pay Agreement

Self-Pay Agreement 

I, _______________________________________, understand and agree to the following terms as a self-pay patient at Beal Wellness: 

1. Self-Pay Responsibility: I acknowledge that I am choosing to receive medical services as a self-pay patient. I am fully responsible for the payment of services rendered to me by Beal Wellness and its providers. 

2. Insurance Opt-Out: I confirm that even if I possess medical insurance, I am opting to bypass insurance processing and payment for services received at Beal Wellness. I understand that Beal Wellness will not submit any claims to my insurance provider on my behalf. 

3. Payment of Services: I agree to pay in full for services at the time they are provided unless other arrangements are made in advance with Beal Wellness. Failure to pay may result in collection actions. 

4. Service Rates: Below are the rates for common services provided at Beal Wellness. I acknowledge that I have been informed of these rates prior to receiving services: 

Beal Wellness Service Rates: 

1. Refund Policy: I understand that all payments are final and refunds will not be issued once services are rendered, except as required by applicable law. 

2. Changes in Financial Status: I agree to inform Beal Wellness if there is any change in my financial situation that may affect my self-pay status. 

3. Questions and Concerns: I agree to contact Beal Wellness directly if I have any questions or concerns regarding my self-pay status, billing, or payments. 

Acknowledgment: 

I have read, understand, and agree to the terms and conditions of this Self-Pay Agreement Form. I acknowledge that this agreement is binding and that I am responsible for payment for services rendered. 

Patient's Signature: ________________________________________ Date: _________________ 

Patient’s Name: _______________________________________________