Self Pay Acknowledgement – Medicaid Clients

For Patients Enrolled in Medicaid:
TP-Health is not a Medicaid-enrolled provider.

You would be accepted as a self-pay patient and are responsible for paying the fees for all services received. We are a fee-for- service practice. This means that payment is due at the time services are rendered.

Our services, which may otherwise be covered by Medicaid if provided by a Medicaid-enrolled provider, are not covered if provided by us. Should you wish for your services to be covered and reimbursed by Medicaid, you must obtain services from a Medicaid-enrolled provider.
You certify this Client Acknowledgement Statement, you acknowledge that you understand that you are being accepted as a self- pay patient, that you are responsible for paying all fees charged for our services, and that no claims will be filed with Medicaid on your behalf.