Common use of Non-Participation in Insurance Clause in Contracts

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-non- governmental insurance plan and to submit any required billing. billing (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINICPRACTICE, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-non- governmental insurance plan and to submit any required billing. billing (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the The Patient’s understanding that neither the CLINICThe Center, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay The Patient pays under this Agreement are covered by your health insurance or other third third-party payment plans. It is the The Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial)billing to them.

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding The Patient understands and agrees that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental nongovernmental insurance plan and to submit any required billing. (Initial).

Non-Participation in Insurance. Your initials on By initialing this clause of the Agreement acknowledges the Patient’s understanding Agreement, You acknowledge that you understand that neither the CLINICPRACTICE, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept have opted out of Medicare eligible patientsand all other government funded plans. We make no representations representa- tions that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third third-party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials The Patient's acceptance of and/or signature on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientsin any form. We make no representations that any fees that You pay the Patient pays under this Agreement are covered by your Patient's health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial).

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the PatientMember’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Member’s health insurance or other third party payment plans. It is the PatientMember’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. ______ (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, CLINIC does not participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. ______ (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial).

Non-Participation in Insurance. Your initials on By initialing this clause of the Agreement acknowledges the Patient’s understanding Agreement, You acknowledge that you understand that neither the CLINICPRACTICE, nor its Physician, participate in any health insurance in- surance or HMO plans or panels and cannot accept have opted out of Medicare eligible patientsand all other government fund- ed plans. We make no representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third third-party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINICPRACTICE, nor its PhysicianProvider, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientspanels. We make no representations that any fees that You you pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. plans (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINICPRACTICE, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-non- governmental insurance plan plan, HSA, or FSA and to submit any required billing. ______ (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third third-party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its PhysicianProvider, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental non-­‐‑governmental insurance plan or HSA and to submit any required billing. ______ (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any your health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its PhysicianProvider, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientspatients for covered services. We make no representations that any fees that You pay under this Agreement are covered by your health insurance or other third third-party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. _Click or tap here to enter text._ (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientsoutside of Original Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. (Initial).

Non-Participation in Insurance. Your initials on this clause of acknowledge the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its PhysicianPhysicians, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patients. We make no representations that any fees that You pay under this the Agreement are covered by your health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan and to submit any required billing. (Initial).

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its PhysicianPhysicians, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. billing (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in will be submitting to any health insurance or HMO plans or panels and cannot accept Medicare eligible patientspanels. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. ______ (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINICPRACTICE, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-non- governmental insurance plan plan, HSA, or FSA and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its PhysicianPhysicians, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. ______ (Initial)

Non-Participation in Insurance. Your Patient’s initials on this clause of the Agreement acknowledges acknowledge the Patient’s understanding that that neither the CLINICClinic, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientsinsurance, with the exception of Medicare. We make Clinic makes no representations that any fees that You pay Patient pays under this Agreement are covered by your Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental non•governmental insurance plan and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINICPRACTICE, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third third-party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-non- governmental insurance plan or HSA and to submit any required billing. ______ (Initial)

Non-Participation in Insurance. Your initials on this clause Section of the Agreement acknowledges the PatientMember’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Member’s health insurance or other third party payment plans. It is the PatientMember’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. (Initial)

Non-Participation in Insurance. Your initials on this clause of the Agreement acknowledges the Patient’s understanding that neither the CLINIC, nor its Physician, participate in any health insurance or HMO plans or panels and cannot accept Medicare eligible patientshave opted out of Medicare. We Neither make no any representations that any the fees that You pay paid under this Agreement are covered by your the Patient’s health insurance or other third party payment plans. It is the Patient’s responsibility to determine whether reimbursement is available from a private, non-governmental insurance plan or HSA and to submit any required billing. ______ (Initial)