Self pay acknowledgement form 2026

1. Click ‘Get Form’ to open the self pay acknowledgement form in the editor.
2. Begin by reviewing the introductory statement regarding your insurance status. This section outlines that the Jackson Regional Women’s Center is no longer accepting your current insurance carrier.
3. In the designated field, confirm your understanding of the self-pay option by checking the appropriate box or typing 'I understand' as required.
4. Next, provide your signature in the 'Patients Signature' field. This confirms your agreement to proceed under self-pay terms.
5. Enter the date of signing in the specified field to document when you acknowledged this agreement.
6. If applicable, have a legal guardian or responsible party sign in their designated area and provide their name for verification.
7. Finally, ensure a witness from Jackson Regional Women’s Center signs where indicated to complete the process.

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