Justin Edward Rome MD PC, BARBER SURGEONS PLLC, and Barber Surgeons Guild PC, (collectively the “Medical Group”) are committed to providing the best quality healthcare services. We do not participate in any insurance plans, including Medicare or Medicaid, and any/all other health insurance plans.  Services provided by the Medical Group  are 100% self-pay by our patients. By signing this form, you acknowledge that either: 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 Medical Group does not accept any health insurance.

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Your 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.

I have read the Agreement for Self-Payment of Services. I understand and agree to this Agreement.

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Patient Consent for Self Pay Agreement:

By clicking the box labeled “Self Pay Agreement”, I agree to the terms described herein, and furthermore, I attest to have read this agreement carefully, and understand the Self Pay Agreement.