[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-359018-105":53,"doc-detail-359018-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","self-pay-agreement-acknowledgement-and-payment-terms","Self-Pay Agreement - Acknowledgement and Payment Terms","","Self-Pay Agreement outlines how Self-Pay patients/legal guardians understand and accept the financial responsibilities for healthcare services at Specialty Outreach Clinics for Children and University Physician’s Inc (UPI). It explains that a bill is issued by UPI for provided services, a signed agreement is required per account, and a minimum deposit is due at the time of service. It states full payment is required after adjustments for the No Insurance Discount (NID), and describes when insurance will not be billed, including elective self-pay scenarios and NID exclusions.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/self-pay-agreement-acknowledgement-and-payment-terms/359018/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/self-pay-agreement-acknowledgement-and-payment-terms/359018.png","ImageObject",442,249,{"name":88,"@type":89},"Alex Sinclair","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-20","2026-09-23",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What actions are required before proceeding with Self-Pay services?","Question",{"text":109,"@type":110},"Self-Pay patients/legal guardians should read the agreement carefully and sign a Self-Pay Agreement for each applicable Specialty Outreach Clinics for Children account before proceeding with care.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When is a minimum deposit required?",{"text":114,"@type":110},"A minimum deposit is required at the time of service.",{"name":116,"@type":107,"acceptedAnswer":117},"In what situations does the No Insurance Discount (NID) not apply?",{"text":118,"@type":110},"The NID does not apply when patients have insurance but choose not to use it, when covered expenses are paid through a health benefits plan, for amounts due under Explanation of Benefits items, or for patients in grants/special programs.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},359018,1791329993,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},1099523882182,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","SELF-PAY AGREEMENT  \nThe Self-Pay Agreement is intended to provide Self-Pay patients/legal guardians with an understanding of the financial aspect of healthcare services provided at Specialty Outreach Clinics for Children and University Physician’s Inc (UPI) . SelfPay patients/legal guardians should read this agreement carefully before making a decision and proceeding with care.  \n• Self-Pay patients/legal guardians will receive a bill from University Physicians Inc (UPI) for healthcare services provided by Specialty Outreach Clinics for Children  \n• A Self-Pay Agreement must be signed for each Specialty Outreach Clinics for Children account for which it applies  \n• Self-Pay patients/legal guardians will be required to make a minimum deposit at the time of service  \n• The patient/legal guardian will be responsible for full payment of charges, less the No Insurance Discount (NID) and less the deposit made at the time of service  \n• UPI will not bill any insurance plan at a later date if the Patient/Legal Guardian elects to be Self Pay at the time of service  \nThe No Insurance Discount (NID) does not apply to:  \n• Patients that have insurance and select not to utilize their insurance  \n• Balances after all covered expenses or eligible services to be paid by a health benefits plan  \n• Amounts due according to the insurance plan Explanation of Benefits (i.e. deductible, co-insurance, and/or copayment)  \n• Patients involved in grants or special programs, as these cases fall into a different set of circumstances  \nThe patient has been registered as Self-Pay due to the following reason marked below:  \n􀂉 The patient/legal guardian does not have insurance coverage  \nOR  \n􀂉 The provider performing the above services or therapies is not a participating provider with my health insurance. There form these services/therapies are not covered by my policy  \n  Bill Insurance   Do Not Bill Insurance (Elective Self Pay)  \n􀂉 The scope of services rendered by this provider may not be covered by my health insurance policy   Bill Insurance   Do Not Bill Insurance (Elective Self Pay)  \n􀂉 The appropriate authorization required by my health insurance policy has not been obtained from my primary care physician. It is my personal decision not to obtain the authorization from my primary care physician  \n  Bill Insurance   Do Not Bill Insurance (Elective Self Pay)  \n􀂉 No claim will be sent to my insurance since it’s my person decision not to use my health insurance benefits for the above service/therapy even though I understand that these services/ therapies are considered covered by my policy (elected – self pay)  \nThe patient/legal guardian elects to have their insurance billed first; the patient/legal guardian will be liable for all balances incurred after all eligible services and covered expenses to be paid by a health benefits plan. The No Insurance Discount (NID) will only apply if the patient’s insurance plan does not cover any services.  \nMy signature below acknowledges receipt of the Self Pay Agreement  \n\n| Patient/Legal Guardian Signature\u003Cbr>Self-Pay Agreement Explained by: | Date |\n| --- | --- |\n\nStaff Name (Print)  \nDate  \nAttach Label","cbCaiiN0SRUYTiLv","https://ap.wps.com/l/cbCaiiN0SRUYTiLv","pdf",323441,"English","# Key Financial Responsibilities\n## Billing, Deposit, and Full Payment Rules\n## No Insurance Discount (NID) Exclusions\n## When Insurance Is or Is Not Billed\n## Self-Pay Reason Selection and Signature Acknowledgement","[{\"question\":\"What actions are required before proceeding with Self-Pay services?\",\"answer\":\"Self-Pay patients/legal guardians should read the agreement carefully and sign a Self-Pay Agreement for each applicable Specialty Outreach Clinics for Children account before proceeding with care.\"},{\"question\":\"When is a minimum deposit required?\",\"answer\":\"A minimum deposit is required at the time of service.\"},{\"question\":\"In what situations does the No Insurance Discount (NID) not apply?\",\"answer\":\"The NID does not apply when patients have insurance but choose not to use it, when covered expenses are paid through a health benefits plan, for amounts due under Explanation of Benefits items, or for patients in grants/special programs.\"}]","Self-Pay Agreement - Acknowledgement and Payment Terms | PDF",1790135885]