Patient Election of Self-Pay Services / Election Revocation Bundle - IQ
Patient Election of Self-Pay Services / Patient Election of Self-Pay Services - Revocation - IQ
Form Type: IntakeQ/PracticeQ – Consent Form - Also available as a PDF form.
Description: Included are two forms: Patient Election of Self-Pay Services and Patient Election of Self-Pay Services - Revocation.
Patient Election of Self-Pay Services is for insured patients who choose to pay out-of-pocket for services, acknowledging their financial responsibility. Patient Election of Self-Pay Services - Revocation revokes that election.
Due to the electronic version of these forms, no refunds will be offered once they are sent to you. Make sure you download any applicable documents along with this purchase. Your purchase will be shared with you via email in 24-48 hours. Make sure you check your junk/spam folder. If you do not receive it, please contact us at support@silverleafpms.com.
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