Self-Pay Financial Policy and Patient Acknowledgment
Right Place Health is committed to providing clear and transparent information regarding charges for patients who pay directly for their care. This policy explains how self-pay services are handled, when payment is due, and your rights regarding cost estimates.
Self-Pay Election
I understand that I am choosing to receive services as a self-pay patient, meaning:
☐ I do not have insurance for these services; or
☐ I am choosing not to use my insurance.
I understand the clinic will not bill my insurance for these services and that I am responsible for payment.
Good Faith Estimate
I understand I have the right to receive a good faith estimate of expected charges before services are provided. I may request an estimate at any time or receive one when scheduling services in advance. I understand the estimate is not a final bill and actual charges may change based on my care. If my bill is $400 or more above the estimate, I may have the right to dispute it.
Accepted Payment Methods:
Right Place Health accepts the following payment methods:
☐ Cash ☐ Check ☐ Credit/Debit ☐ HSA/FSA ☐ Apple Pay ☐ Google Pay
Payment is due at the time of service unless other arrangements have been approved in advance.
Fees and Additional Charges
● Charges may include visits, procedures, supplies, and related services.
● Administrative forms, letters, and custom documentation requests may incur an additional fee. The fee will generally range from $50.00 to $75.00, depending on the request, and is payable when the request is submitted unless other arrangements have been approved in advance. Please allow 2 to 3 business days for completion. Requests for copies of existing medical records will be handled in accordance with applicable law.
● Outside providers (lab, imaging, specialists) may bill separately.
● Right Place Health does not control third-party billing practices, insurance participation, reimbursement decisions, or collection activities.
● Missed appointments or appointments cancelled with less than 24 hours’ notice will incur a fee of $30.00.
Insurance Reimbursement
I understand that Right Place Health is not contracted with insurance plans and will not bill insurance for services I receive as a self-pay patient. If I choose to seek reimbursement, I am responsible for confirming coverage, claim requirements, and reimbursement status with my insurance plan.
Upon request, Right Place Health may provide an itemized receipt or billing statement for my records or for submission to my insurance plan, if applicable. I understand that providing an itemized receipt or billing statement does not guarantee reimbursement, and I remain responsible for payment regardless of whether I receive reimbursement.
I understand that Medicare-covered services are subject to separate rules and generally may not be provided on a self-pay basis or submitted for reimbursement except as permitted by law.
Prepaid Appointments and Account Credits
I understand that Right Place Health may allow or require payment when an appointment is scheduled or confirmed. If Right Place Health cancels an appointment, any prepaid amount for that appointment will be refunded or applied as a credit to a rescheduled appointment. If I cancel within the required cancellation period, any prepaid amount will be refunded or applied as a credit to a future appointment. If I miss an appointment or cancel late, I understand that a missed or late-cancellation fee may apply and may be deducted from any prepaid amount or account credit. Any remaining credit balance will be refunded or applied to a future appointment.
Collctions and Returned Payments
Returned checks will incur a fee of $25.00. Unpaid balances may be referred to collections as permitted by law. Patients are responsible for maintaining current billing, mailing, email, and contact information with the clinic.
Telehealth Services
I understand that telehealth visits are billed at the same rate as in-person visits unless otherwise posted. Telehealth visits may be subject to a separate telehealth policy or consent form.
Patient Acknowledgement and Agreement
By signing below, I confirm that:
● I understand and agree to this Self-Pay Financial Policy;
● I have had the opportunity to ask questions;
● I understand my rights regarding good faith estimates.
Person Completing this Form (Required)
☐I am the patient
☐I am a helper assisting the patient complete this form
☐I am a Legal Representative of this patient (I have completed the Legal Representative form)
Signature (Patient/Responsible Party):
______________________________________________
Printed Name: ________________________________________________
Date: ________________________________________________________
Office Use Only:
☐ Copy provided
☐ Good faith estimate offered/provided (if applicable)