Self Pay Form

Self-Pay Form

You are being provided this letter of acknowledgment because you have requested that your services be deemed as “self-pay” and you will not be submitting the claim to an insurance carrier. You have requested that this service be deemed as self-pay because

Initial One:

I have no health insurance.

I have health insurance but have been informed we do not file out-of-network benefits.

I have health insurance, but have chosen to self-pay, and understand that codes cannot be provided for insurance filing, and a claim cannot be submitted.

We want you to know what to expect so that you can make an informed decision. In order to accomplish this, by signing below you agree to the following:

  • I understand and acknowledge the procedures I seek will be considered cosmetic and it would be fraudulent and unethical for AIPS and/or Surgery Center of Texas to submit a charge to any insurance company for payment after services have been rendered.

  • I understand that AIPS and/or Surgery Center of Texas will not accept insurance for any procedures such as liposuction, facial feminization, breast augmentation, abdominal tightening, any MedSpa treatments, and extra skin removal.

  • I understand that AIPS and/or Surgery Center of Texas have my consent to not accept assignments from any insurance company, managed care provider, or another coverage source.

  • I understand that the self-pay amount is considered a “bundled” fee and will cover professional, facility, anesthesia, lab, and pathology services.

By my signature below, I acknowledge and agree to waive my insurance for any and all medical services at the American Institute of Plastic Surgery and Surgery Center of Texas. I understand I will be seen on a Self-Pay basis and will be 100% responsible for any associated charges pertaining to these services.

I confirm that I am the patient, or the patient’s duly authorized representative and agree that by accepting the self-pay agreement that I will not file my insurance after services have been rendered.

Patient or Representative Signature


If signed by someone other than the patient, please specify the relationship to the patient:

Interpreter Signature


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