Self-Payment of Service

Agreement for Self-Payment of Services

WAYS2WELL is committed to providing the best quality healthcare services. Depending on your insurance coverage, your health plan might not reimburse you for these wellness services. We will provide you an itemized statement and receipt, which you can use as documentation should you choose to seek reimbursement from your insurance plan, employer, an employer-sponsored medical savings account.

Your insurance policy is a contract between you and your insurance company. It is your responsibility to know your benefits, and how they will apply to your benefit payments, and we take no responsibility to understand or be bound by the terms and conditions of such insurance. By acknowledging this form, you are electing to purchase services that may or may not be covered by your insurance if you obtained those services from a different provider or if you obtained them through an in-person consult. You have selected services for purchase from us on a self-pay basis and have directed us to treat your purchase of these services as if you are an uninsured patient and you agree to be responsible for full payment of the services. There is no guarantee your insurance company will make any payment on the cost of the services you have purchased.

WAYS2WELL has provided you with the charges, in advance, for the services you have requested. You have been given a choice of different services, along with their costs. You have selected the services and are willing to accept full financial responsibility for payment.

*** All bloodwork will be charged to your account once the lab order is placed. If the patient chooses not to participate in the wellness program and has not yet had their labs drawn, a refund can be requested within 30 days of the initial appointment. Refunds will not apply to any services that have been rendered. ***

I have read the Agreement for Self-Payment of Services. I understand and agree to this Agreement.

If you have any questions, please contact us at 1-800-321-0864 or email us at