This Petition Slip is for you to present to the named Healthcare Provider as a written request for a price break on the office visit/service appointment which you are responsible to schedule. If a price break has not been determined prior to your appointment, feel free to remind the Healthcare Provider/staff that you are paying out-of-pocket that day. At this time it is important for you to ask the Healthcare Provider which form of payment they accept; Cash, Check or Charge.
PAYMENT DUE
When checking in at your appointment, payment will be required prior to receiving service.
HEALTHCARE PROVIDER Name:
SERVICE PRICE PETITION
Office visit/service price to be determined between Patient and Healthcare Provider
PROVIDER SIGN-UP
Please ask your Healthcare Provider to visit MEDPRICE.COM to review the enrollment process. Our basic program allows Healthcare Providers to enroll as an Associate starting as low as $9.95 per month. It is designed to eliminate the 'sometimes awkward' face to face price negotiations with patients and to simplify the out-of-pocket payment method.
Print this out and take it with you to your appointment.
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