Get Self Pay Agreement Form

Filling out the Self Pay Agreement Form online is a straightforward process that ensures you understand your financial responsibilities for services received. This guide will provide clear instructions to help you complete each section of the form accurately and effectively.

Follow the steps to complete your Self Pay Agreement Form successfully.

1. Press the ‘Get Form’ button to access the Self Pay Agreement Form and open it for editing.
2. Enter your full name in the designated field, ensuring it is legibly printed as it will be associated with your medical records.
3. Input your UCLA Medical Record Number in the corresponding section; this number is vital for tracking your health services.
4. Review the agreement details regarding your financial responsibilities. Ensure you understand that all charges are due on the day of service unless prior arrangements have been made.
5. Sign the form in the space provided to indicate your agreement to the terms outlined. Confirm your signature matches the name you printed earlier.
6. Enter today's date in the specified area below your signature to note when the agreement was entered into.
7. If applicable, have a UCLA representative complete their section by printing their name and signing the document alongside the date.
8. After completing all fields, ensure to save your changes, and if necessary, download, print, or share the completed form as needed.

Complete your Self Pay Agreement Form online today to ensure a seamless process for your healthcare services.