Election to Self-Pay for Services

1. Advanced Respiratory and Sleep Medicine (“clinic”) may be a participating provider with your insurance.
2. The health plan under which you are covered may include benefits for some or all of the services provided by clinic.
3. Despite the above, you understand that a claim will not be submitted to your insurance.
4. By election to self-pay for services, any payments you make to clinic will not be credited toward satisfying any deductible you may be subject to under my health insurance plan with company unless otherwise permitted under the terms of my health plan.
5. You have read this Election to Self-Pay for Services form and have had the opportunity to asked any questions you may have had about the form. Any questions you may have had about this form have been answered to your satisfaction.
6. You have freely chosen to self-pay for services after having carefully considered all options.