Agreement for Self-Payment of Services 

Last modified: February 24, 2022

Dr. B Medical Group (DE), P.A and affiliated medical groups (collectively, Dr. B Medical Group)  is committed to providing the best quality healthcare services. We do not participate in any  insurance plans, including Medicare or Medicaid, and we do not accept any health insurance  whatsoever. Our services are 100% self-pay by our patients. By signing this form, you  acknowledge that: 1) you do not have any health insurance through a PPO, HMO, Medicaid or  Medicare or any other insurance plan; or 2) you have health insurance but you do not want to use  any insurance benefit for these services, acknowledging that Dr. B Medical Group does not accept  any health insurance.  

Your insurance policy is a contract between you and your insurance company. It is your  responsibility to know your benefits, and how they will apply to your benefit payments, and we  take no responsibility to understand or be bound by the terms and conditions of such insurance.  By signing this form, you are electing to purchase services that may or may not be covered by your  insurance if you obtained those services from a different provider. You have selected services for  purchase from us on a self-pay basis. In other words, you have directed us to treat your purchase  of these services as if you are an uninsured patient and you agree to be 100% responsible for full  payment of the listed price of the services. There is no guarantee your insurance company will  make any payment on the cost of the services you have purchased.  

Dr. B Medical Group has provided you with the charges, in advance, for the services you have requested. You agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit.  You have been given a choice of different services, along with their costs.  You have selected the services and are willing to accept full financial responsibility for payment.