VCF Private Pay Waiver

Please select one of the options below

By signing this waiver, I am acknowledging that Virtual Care for Families is accepting my child or myself as applicable as a Private Pay Patient. I am paying by cash, check, or credit card for the services that are to be provided today, and therefore my child is not enrolled in either Medicaid, CHIP, or Managed Medicaid (MCO) insurance plans for covered services. Covered services include: all general illness and injury provider visits. I understand that if my child does have Medicaid, CHIP, or a managed Medicaid (MCO) plan and I proceed with paying out of pocket for covered services rendered, it will be in violation of my child's insurance plan and will put the plan in jeopardy to be revoked.

By signing this waiver, I understand that Virtual Care for Families is accepting my child or myself as applicable as a Private Pay Patient for the purpose of COVID-19 testing for travel or recreational purposes. This is considered a non-covered service. The cost of the rapid COVID-19 test is $50 and the PCR is $85. If my child does have Medicaid, CHIP, a Managed Medicaid Plan (MCO), and/or any other commercial insurance plan, I understand that I have the right to pay privately for this non-covered service at the established Private Pay rate.

Any virtual visit that is paid out of pocket is not eligible to be submitted to insurance and/or Medicaid, CHIP, and/or Managed Medicaid Plans (MCO) by Virtual Care for Families on your behalf because it is offered at a discounted Private Pay rate. Receipts for Private Pay visits, sports physicals, flu vaccines, or COVID-19 testing for travel or recreational purposes can be submitted by the patient or parent to their own insurance company if their plan has reimbursement programs. Please bear in mind that reimbursement programs vary by insurance company and plan. Please call your insurance company for more information about your individual plan.

Patient First Name

Patient Last Name

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Signature

Use your mouse or finger to draw your signature above.

VCF Private Pay Waiver

We're here for you when it matters most.

Login