Biocorrect LLC Self Pay Form

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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.

Please check the box below to acknowledge that you are receiving telehealth services

Patient is choosing to receive telehealth services.

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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