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Medical Self Pay Agreement Form
"I need a Medical Self Pay Agreement Form for my small dental practice that includes flexible payment plan options and specific provisions for elderly patients, to be implemented from March 2025."
1. Parties: Identifies the healthcare provider and patient entering into the agreement
2. Background: Explains the context of the self-pay arrangement and acknowledgment of non-insurance coverage
3. Definitions: Defines key terms used throughout the agreement including medical services, payment terms, and other relevant terminology
4. Payment Terms: Details the payment structure, amounts, and timeline for payments
5. Patient Responsibilities: Outlines the patient's obligations under the agreement including payment commitments and information disclosure requirements
6. Provider Responsibilities: Specifies the healthcare provider's commitments and obligations regarding service delivery and billing
7. Default and Remedies: Explains consequences of payment default and available remedies for both parties
8. Governing Law: Specifies applicable jurisdiction and legal framework governing the agreement
1. Financial Hardship Provisions: Terms for handling financial difficulties and criteria for financial assistance programs
2. Insurance Disclaimer: Clarification regarding non-coverage by insurance and patient's acknowledgment of responsibility
3. Alternative Dispute Resolution: Procedures for resolving disputes through mediation or arbitration before pursuing legal action
1. Schedule A - Fee Schedule: Detailed breakdown of medical services costs and standard charges
2. Schedule B - Payment Plan Calculator: Tool for calculating payment installments and payment plan options
3. Schedule C - Financial Assistance Policy: Details of available financial assistance programs and qualification criteria
4. Schedule D - Privacy Notice: HIPAA-compliant privacy practices explanation and patient rights regarding medical information
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