Please take a moment to respond to these important questions. This information will be handled confidentially for your protection. If you have any concerns please review our Privacy Declaration.
Please take a moment to respond to these important questions. This information will be handled confidentially for your protection. If you have any concerns please review our Privacy Declaration.
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.
When checking in at your appointment, payment will be required prior to receiving service.
Name:
Location: , , , ,
Phone:
Office visit/service price to be determined between Patient and Healthcare Provider
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.
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.
When checking in at your appointment, payment will be required prior to receiving service.
Name:
Location: , , , ,
Phone:
Office visit/service price to be determined between Patient and Healthcare Provider
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.