Patient Election to Self Pay & Revocation

It’s not uncommon to see patients with deductibles in the $3-$10,000 range these days. If you are a network provider, you know that your provider agreements require you to file claims with the insurance carrier. We want to be a good corporate citizen and encourage you to honor those agreements. But, we also have an obligation to let patients know what their payment options are. Thanks to HIPAA/HITECH regulations you now have the ability to have a patient opt out of filing their health insurance. The only caveat is they must pay you in full.

If a patient elects to opt out of their insurance you should have them sign an election to self-pay form located below. By signing the Election to Self Pay the patient is stating that they have chosen to opt-out of their insurance and by doing so, you will not be filing a claim with their insurance company and if the patient were to file a claim on their own, there is no guarantee it will apply towards their deductible since the patient chose not to use their insurance. Also below is a revocation of self-pay in the event the patient meets their deductible and would like you to begin using their insurance.

The conversation with the patient goes like this:

Staff: Mrs. Jones, we verified your insurance benefits and you have a $5000 deductible. In most cases similar to yours, it’s not uncommon for care to run $90 to $100 per visit, and that is what you would be expected to pay until your deductible is met. Honestly, most patients hardly ever reach a deductible that high in our office and find that it’s more affordable for them NOT to file their insurance, if they have one of those discount medical cards like ChiroHealthUSA, do you have one of those?


Staff: Mrs. Jones, most patients with a high deductible like this will never meet it in our office and they find care is more affordable if they are part of a discount medical plan, are you a member of one of those?


Patient: No

Staff: Not a problem, that is why we are part of ChiroHealthUSA, that’s a network you can join in our office today for $49.00 for the year, and it covers you AND your family. Under this plan, your visits would be $45.00 per visit instead of $90-100 per visit. Would you like to hear more about that?

Patient: Sure

Staff: If you choose to do this you will be opting out of us filing your health insurance for you and we would provide you with a receipt for your visit. Once you join the network, there is a simple form call the “Election to Self-Pay that outlines this process.

Patient Election To
Self-Pay Form



Revocation of Patient
Election To Self Pay Form