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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.
I, give TP-Health permission to disclose relevant health information including not limited to: (your health status, treatment, and payment arrangements) to
By my signature below, I acknowledge that I have read and understood each and every policy mentioned above in detail and I consent to abide by those policies.
I also acknowledge that the information provided above is true and correct. I also understand that any wrong information may render for refusal of this appointment application by TP-Health.
I also declare that I have signed this document voluntarily and of my own free will. I agree that any questions I may have, have been answered.
