Cash Pay Pricing

I understand and agree to the following conditions regarding the lab service listed above:

• The service is being provided to me on a cash-pay basis.

• I acknowledge and agree that this service will not be submitted as a claim to any federal health care program (e.g., Medicare, Medicaid) or any private commercial insurance. (Note: An Advance Beneficiary Notice (ABN) is typically only required for Original Medicare patients when services are expected to be denied; for all other self-pay, a waiver of liability is appropriate.)

• I agree to pay the Practice directly for this service at the stated cash-pay fee.

• I waive any right to claim insurance reimbursement for this service. I understand that by signing this waiver, I am personally and solely responsible for the entire cost of the lab service.