Cash Pay

 Patient Cash Pay Acknowledgment

I understand and agree that I must pay the full amount of the costs associated with this

telemedicine service, including any prescription I may receive, and I will not attempt to

submit a claim to Medicare, any other federal payor, or any state or private insurer. 

 

 

By checking the box, I agree that I have read, understand, and consent to the

foregoing acknowledgments and conditions.