Biocorrect LLC Self Pay Form


You have requested that you or your dependent’s initial evaluations be delivered via telehealth as a “self-pay” service. By signing this form, you are acknowledging that you understand that the Provider will not be billing any insurance carrier for services provided, and that you are subject to the self-pay policies and guidelines of the Provider as listed below.

Please be aware that:
  • Self-pay services must be paid in full on the date of service.
  • We will provide you with an itemized receipt that you can submit to your insurance company for possible reimbursement.

Patient Self-Pay Program
Cost Per Visit: $450 and includes the following: 

1.) Initial Evaluation - approximately 30 min appointment
2.) One pair of bilateral custom orthotics
3.) Three follow-up appointments within one year of the initial evaluation

By signing below, I attest that I meet the requirements to participate in the Patient Self Pay. The contents of this form have been explained to me, and I have voluntarily signed this agreement before receiving the described services. I have been told what the estimated costs will be. I agree to pay for the services in full or within the guidelines of a formally established payment plan between myself and the Provider.
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