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Licensed Marriage & Family Therapist 235 E. Broadway, Suite 524 Long Beach, CA 90802 7608227729 www.denisehockley.com email denisehockley.comSELFPAY AGREEMENT I, (client name), am I signing this agreement

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How to fill out self-pay agreement

01

Read through the self-pay agreement form carefully to understand the terms and conditions.

02

Provide your personal details such as name, contact information, and address.

03

Fill in the date on which you are signing the agreement.

04

Check the option that specifies the payment method you will be using for self-pay.

05

Specify the services or items for which you are opting for self-pay.

06

Agree to the terms and conditions stated in the agreement by signing and dating it.

07

Keep a copy of the filled self-pay agreement for your records.

Who needs self-pay agreement?

01

Individuals who do not have health insurance and are responsible for covering their medical expenses.

02

Patients who are receiving services or treatments that are not covered by their insurance.

03

People who prefer to pay directly for healthcare services without involving insurance companies.

04

Self-employed individuals or freelancers who do not have employer-provided health insurance.

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What is self-pay agreement?

Self-pay agreement is a contract between a patient and a healthcare provider where the patient agrees to pay for medical services out-of-pocket.

Who is required to file self-pay agreement?

Both the patient and the healthcare provider are required to file a self-pay agreement.

How to fill out self-pay agreement?

To fill out a self-pay agreement, the patient and the healthcare provider need to agree on the terms of payment and sign the contract.

What is the purpose of self-pay agreement?

The purpose of a self-pay agreement is to establish a payment plan for medical services that are not covered by insurance.

What information must be reported on self-pay agreement?

A self-pay agreement must include details of the medical services provided, the cost of those services, and the payment schedule.

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