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.

You have requested that this service be coded as self-pay because:




I, the undersigned patient, acknowledge that I understand and agree that:

  1. Northwest Acupuncture, PS (DBA Acupuncture NW & Associates) ("Clinic") is a participating provider with (Insurance "Company").
  2. I am covered by one of the Company health insurance plans.
  3. The health plan under which I am covered includes benefits for some or all of the services provided by Clinic.
  4. Despite the above, I do not wish Clinic to submit a claim to Company for services provided to me by Clinic.
  5. Until such time as I may otherwise advise Clinic in writing, I elect to pay for all services I receive from Clinic at their discounted rates.
  6. By election to self-pay for services, any payments I make to Clinic will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with Company unless otherwise permitted under the terms of my health plan. Once you self-pay, we will not bill your insurance until you revoke this election and you will not receive a superbill.
  7. I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.
  8. I have freely chosen to self-pay for services after having asked Clinic about payment options and having carefully considered those options.

By my signature below, I acknowledge that I have read and understand the above and have been given the opportunity to ask questions. I confirm that I am the patient, or the patient's duly authorized representative.

If submitted/signed by someone other than the patient, please specify relationship to the patient:

-NOT PART OF THE LEGAL MEDICAL RECORD-