Healthcare Self Pay Agreement

Doctor Matrix Medical Group has provided you with the fees in advance 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 self-paying patient and you decide not to use any insurance benefit. You have the choice between different services and their cost. 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 are applied to your benefits, and we have no responsibility to understand or be bound by the terms of such insurance. By signing this form, you are opting to purchase services that may or may not be covered by your insurance if you have received these services from another provider. You have selected services for purchase from us on a self-payment basis. In other words, you have directed 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 quoted price of the services. There is no guarantee that your insurance company will pay the cost of the services you have purchased. The Doctor Matrix Medical Group strives to provide optimal quality health services. We do not participate in insurance plans, including Medicare or Medicaid, and we do not accept any health insurance.

Our services are paid for 100% by our patients themselves. By signing this form, you acknowledge that: 1) you do not have health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or 2) You are covered by health insurance, but you do not wish to receive insurance benefit for these services, as Doctor Matrix Medical Group does not accept health insurance. I have read the agreement on self-payment for services. I understand and agree with this agreement. .