PATIENT ELECTION TO SELF-PAY FOR SERVICES

Patient election to self-pay for services
ROSABEL M BENCOMO M.D P. A

6840 SW 40th Street, Suite 209, Miami, FL 33155

Telemedicine: (786) 800-2430 | Office: (786) 222-8807 | Fax: (305) 763-8379
I, *
the undersigned patient, acknowledge that I understand and agree:
1. MDteleMe | Rosabel M Bencomo , (“ the Clinic”) is a participating provider with:
(“the Health Insurance Company”). *
Health Insurance Company name
2. I am covered by one of the Company’s health insurance plans.

3. The health plan under which I am covered includes benefits for some or all the services provided by the Clinic.

4. Despite the above, I do not wish the Clinic to submit a claim to the Company for the services provided to me by the Clinic.

5. Until such time as I may otherwise advise the Clinic in writing, I elect to pay for all services I receive from the Clinic at their MDteleMe | Rosabel M Bencomo’s discounted rates.

6. By election to self-pay for services, any payments I make to the Clinic will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with the Company unless it is otherwise permitted under the terms of my health plan.

7. I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form.

8. Any questions I may have had about this form have been answered to my satisfaction.

9. I have freely chosen to self-pay for services after having asked the Clinic about payment options having carefully considered those options.
Signature of patient or responsible party if patient is a minor or is otherwise unable to sign for him/herself
Signature: *

Clear
Date: *

Month Day Year
Date
Printed Name of Patient or Responsible Party *
Email
example@example.com
Capacity of Responsible Party e.g. parent, guardian, etc
Should be Empty:

Patient election to self-pay for services