Acknowledgement of Self-Pay Status: I acknowledge that SleepMedRx LLC is a "Cash Pay" practice that is not enrolled in Medicare, or any insurance plans.

By consenting to this purchase, I am opting to pay for the medical services received in cash and do not wish to utilize insurance coverage for the specified treatment or consultation.
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I understand that by choosing to be treated by SleepMedRx LLC and receive cash pay services:

1. I will be responsible for the full payment of the services rendered.
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2. No insurance claims will be submitted on my behalf for the forementioned services.
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3. I will not be eligible for any reimbursement from my insurance provider for these services.
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I further acknowledge that I have received a good faith estimate of the services being provided to me. I understand that any additional services rendered will be invoiced, and I will be responsible for the full payment of those services. I confirm that I have read, understood, and agree to the terms outlined in this acknowledgment.