Get Self Pay Agreement Form

Filling out the Self Pay Agreement Form online is a straightforward process designed to ensure you understand your financial responsibilities for services. By following these simple steps, you can complete the form efficiently and accurately.

Follow the steps to complete the Self Pay Agreement Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date in the 'Today’s Date' field. This field should reflect the date you are completing the agreement.
3. Fill in your full name in the 'Client Name' section to identify yourself clearly.
4. Provide your MR (Medical Record) number in the designated field; this number is essential for tracking your treatment.
5. Input your date of birth (DOB) to verify your identity and age.
6. Complete the Social Security number (SS#) section; this information may be required for billing purposes.
7. Carefully read the Self Pay Financial Policy statement provided and ensure you understand your payment responsibilities.
8. Sign the agreement in the 'Client/Guardian Signature' area to confirm your acceptance of the terms.
9. Enter the date of your signature in the 'Date' field to document when you agreed to the terms.
10. Print your full name in the 'Client/Guardian Printed Name' section to ensure clarity.
11. Specify your relationship to the client in the 'Relationship to client' field, if applicable.
12. After completing all sections, review your entries for accuracy, then save your changes, download, print, or share the filled form as needed.

Complete your Self Pay Agreement Form online today for a smooth and efficient process.