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Well Woman PAP Exam Self-Pay

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I, the undersigned patient, acknowledge that HIPAA/HITECH regulations offers the ability for me to opt out of filing my health insurance (if applicable) for healthcare services rendered. I understand that as part of the regulation I am financially  responsible to pay in full for all services rendered. I understand and agree that Internal Medicine Associates of Jasper, PC. (Dba Prestige Medical Group) will:

  1. Require all monies in full, at time of service, for the performance and specimen collection.
  2. Forward specimen to Quest Diagnostics Lab to be fully processed for results. 
  3. Is a completely separate entity, and is not responsible for the additional fees that I will accrue from Quest Diagnostics in order to obtain results from my exam. 

I understand that the fees collected by Prestige Medical Group in regards to my Well Woman / Pap Exam are for the performance of the exam itself, and only covers the collection of the specimen. I understand that they must send the specimen to Quest for processing, in which will accrue separate fees to be billed to me by Quest Diagnostics. 

I understand that all tests, ordered by my medical provider, correlate with my PAP exam based on my provider's professional recommendations. I am aware that those pathology charges will be billed to me separately by Quest. Those studies will include, but not be limited to: Cytopathology, HPV, STD screenings, etc. 

I acknowledge my full understanding, and I am prepared to pay to Prestige Medical Group in order to proceed with my Well Woman / PAP exam today. 

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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