Agreement for Self-Payment of Services
Last updated Aug 1, 2023Easycare Medical Partners, P.A. and affiliated medical groups (collectively, “Easycare”) and other independent practices listed on the Sesame platform are committed to providing the best quality healthcare services. Easycare does not participate in any insurance plans, including Medicare or Medicaid, and we do not accept any health insurance whatsoever. Services listed on Sesame are 100% self-pay by patients.By accepting this agreement, you acknowledge that: 1) you do not have any health insurance through a PPO, HMO, Medicaid or Medicare or any other insurance plan; or 2) you have health insurance but you do not want to use any insurance benefit for these services, acknowledging that the Sesame platform and Easycare do not accept any health insuranceYour insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance. By signing this form, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider. You have selected services for purchase from us on a self-pay basis. In other words, you have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be 100% responsible for full payment of the listed price of the services. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased.Easycare, the Sesame platform, and/or other independent practices listed on the Sesame platform have provided you with the charges, in advance, for the services you have requested. These prices provided include the provider’s charges as well as platform/service fees charged by Sesame. Prices charged through Sesame include any fees that your doctor or medical provider charges and a platform fee that helps Sesame maintain and develop the software platform. The fees vary on Sesame, depending on the service.By signing below, you agree to pay these charges in full as a self-pay patient, electing not to use an insurance policy benefit. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment.I have read the Agreement for Self-Payment of Services. I understand and agree to this Agreement.Join our mailing list for exclusive promos, curated health content & more.