The Medical Self Pay Agreement Form is essential in Philippine healthcare settings where patients choose to or must pay directly for medical services without insurance coverage or third-party payment assistance. This document becomes necessary when patients require medical services and agree to assume direct financial responsibility for their care. It is designed to comply with Philippine healthcare regulations, including RA 11223 (Universal Health Care Act), RA 7394 (Consumer Act), and RA 10173 (Data Privacy Act). The agreement outlines payment terms, service costs, patient rights, and provider obligations, while ensuring transparency in medical billing and protecting both parties' interests. It is particularly relevant in private healthcare facilities, outpatient clinics, and hospitals where direct payment arrangements are common.
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1. Parties: Identifies the healthcare provider and the patient (self-pay guarantor), including complete contact information
2. Background: Explains the context of the agreement - that the patient is seeking medical services and choosing to pay directly rather than through insurance
3. Definitions: Defines key terms used throughout the agreement, including 'Medical Services', 'Charges', 'Payment Plan', etc.
4. Services and Charges: Details the medical services to be provided and associated costs, including standard fees and potential additional charges
5. Payment Terms: Specifies payment schedule, accepted payment methods, and due dates
6. Patient Rights and Responsibilities: Outlines the patient's rights under Philippine law and their responsibilities regarding payment and communication
7. Healthcare Provider Obligations: Details the obligations of the healthcare provider in delivering services and maintaining transparency in billing
8. Billing Procedures: Explains how and when bills will be presented, itemization requirements, and dispute procedures
9. Default and Remedies: Describes what constitutes payment default and the legal remedies available, compliant with RA 9439
10. Confidentiality and Data Privacy: Addresses the handling of patient information in compliance with the Data Privacy Act
11. Governing Law: Specifies that the agreement is governed by Philippine law and identifies relevant jurisdictions
12. Execution: Signature block and execution details for all parties
1. Payment Plan Details: Include when the patient requires an installment payment arrangement
2. Third-Party Guarantor: Include when someone other than the patient is assuming financial responsibility
3. Emergency Services Provision: Include for agreements covering emergency or urgent care services
4. Insurance Opt-Out Declaration: Include when the patient has insurance but chooses to self-pay
5. Charity Care Options: Include when the healthcare provider offers charitable programs or sliding scale fees
6. Language Access: Include when the patient requires documentation in languages other than English or Filipino
1. Schedule A - Fee Schedule: Detailed breakdown of standard charges for medical services
2. Schedule B - Payment Plan Terms: Specific terms and schedule of payments if installment payments are arranged
3. Schedule C - Required Documents: List of documents required from the patient for billing and medical records
4. Appendix 1 - Patient Rights Charter: Comprehensive list of patient rights under Philippine healthcare laws
5. Appendix 2 - Billing Procedures Manual: Detailed procedures for billing, payment processing, and dispute resolution
6. Appendix 3 - Privacy Policy: Detailed privacy policy and data protection measures in compliance with RA 10173
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