ACKNOWLEDGEMENT OF DIRECT PAY
I hereby acknowledge and agree that I understand that payment for the services being provided by Marek Health and its service providers will be billed to and paid by me directly, that Marek Health will not bill any insurance or other third party payers directly, regardless of whether such services may or may not be covered by any insurance or other programs offered by third party payers.
I further acknowledge and agree that I am aware and understand that neither Marek Health, nor its services providers, have made any representation or warranty that any services, treatment or any other portion of the services provided by Marek Health and/or its service providers are or will be covered by or qualify for reimbursement or assignment under Medicare, Medicaid, and/or other federal/state government or private insurance program.
I hereby covenant to Marek Health that I WILL NOT submit any claim to Medicare, Medicaid, and/or other federal/state government or private insurance program for any portion of the services provided by Marek Health or its service providers at any time and further agree to indemnify Marek Health and its members, managers, and service providers against any claims, action, loss or suit and associated costs (including attorney fees) which result either directly or indirectly from my submission, or any submission by a representative or authorized agent on my behalf, of a claim for any portion of the services provided by Marek Health or its service providers to Medicare, Medicaid, and/or other federal/state government or private insurance program.
I understand that all Marek Health web sales are final and non-refundable, and payment collected at booking is a non-refundable deposit that can be used towards any product or service at Marek Health. I understand and acknowledge Marek Health’s refund policy. Web sales are final and cannot be canceled once an order has been placed. All Marek Health appointment cancellations without a reschedule request are nonrefundable. Reschedule requests must be made a minimum of 24 hours’ notice before the scheduled appointment, or they may be subject to a non-refundable fee up to $50. Missed appointments may also be subject to a nonrefundable fee up to $50. Please be advised that cancellations made up to 24 hours before a scheduled appointment via email, text, or phone will be processed without penalty. If Marek Health cancels an appointment with less than 24 hours’ notice, a new appointment will be scheduled without penalty to the client, subject to availability.
I acknowledge and agree that this Acknowledgment of Direct Pay was executed by me before services were rendered by Marek Health or its service providers and that I am not experiencing an urgent or emergency health situation.