Election to Self-Pay for Services Form
HIPAA Request to Restrict Disclosure of Healthcare Items or Services to Health Plans
When Patients Self Pay Out of Pocket
I request that Acupuncture Northwest & Associates not disclose healthcare items or services to my health plan because I am choosing to self-pay.
I understand that:
- I must pay the full amount for these services must on the date of service.
- These claims will not be submitted to my insurance carrier by myself or Acupuncture Northwest & Associates or applied to your deductible.
-NOT PART OF THE LEGAL MEDICAL RECORD-