Medical Self Pay Agreement Form
Dr. Matrix Medical Group has made available to you in advance the fees for the services you have requested. Your continued use of our website represents your consent, you agree to pay these fees in full as a payer and choose not to receive insurance benefits. They have a selection of different services, as well as their costs. You have selected the services and are ready to take full financial responsibility for the payment. Your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits and how they apply to your benefits, and we assume no responsibility to understand or be related to the terms of such insurance. By signing this form, you choose to purchase services that may be covered by your insurance if you purchased these services from another provider. You have selected services to buy from us on a payment basis. In other words, you have ordered us to treat your purchase of these services as if you were an uninsured patient and you agree to be 100% responsible for the full payment of the stated price of the services.
There is no guarantee that your insurance will cover a payment on the costs of the services you have purchased. The Doctor Matrix Medical Group is committed to providing quality health quality services. We do not participate in insurance plans, including Medicare or Medicaid, and we do not accept health insurance. Our services are 100% self-payment by our patients. By signing this form, you recognize that: 1) you do not have health insurance through an OPP, HMO, Medicaid or Medicare or any other insurance plan; or 2) you have health insurance, but you do not want to receive insurance for these services because you recognize that the Doctor Matrix Medical Group does not accept health insurance. I read the agreement on self-payment of services. I understand and agree with that agreement.