Advance Beneficiary Notice "*" indicates required fields Today's Date MM slash DD slash YYYY Patient Name* First Name Middle Initial Last Name Email* Date of Birth* MM slash DD slash YYYY Responsible Party* Patient Guardian or Legal Representative If patient is a minor or has a legal representative or guardian, additional information is needed.Responsible Party* First Last Responsible Party Email* Primary Insurance* Primary Insurance Policy Number* If the insurance plan does not pay for the medical services listed below, or we do not participate in your insurance plan, you will be required to pay out of pocket. The insurance plans do not pay for everything, even some care that you or your health care provider have good reason to think you need. Service(s)/Reason(s):* Tele-Psychiatry Non Par w/ Insurance Other Other Service(s)/Reason(s):* Reason the Insurance Plan May Not Pay: Non-covered service or Not in network provider Estimated cost: $85-$250 depending on treatment. Cost may vary depending on the service/s WHAT YOU NEED TO DO NOW: Read this notice, so you can make an informed decision about your care. Please feel free to ask any questions that you may have after you finish reading this form. Choose the preferred option below. Choose an Option* Option 1. I want the medical service/s listed above. I will be asked to pay now, and I also want the insurance company billed for an official decision on payment. This is sent to me on an Explanation of Benefits (EOB) from the insurance company. I understand that if the insurance plan does not pay, I am responsible for payment, but I can appeal to the insurance plan by following the directions on the EOB. If the insurance plan does pay, NeuroPsychiatry Center will refund any payments I made to you, less co-pays or deductibles. Option 2. I want the service/s listed above, but do not bill the insurance plan. I will be asked to pay now as I am responsible for payment. I cannot appeal if the insurance plan is not billed. Option 3. I do not want the service/s listed above. I understand with this choice, I will not receive the services listed above and I am not responsible for payment. I cannot appeal if the insurance plan is not billed. This notice is not an official insurance plan decision. If you have other questions on this notice regarding insurance billing, please call your insurance company. Signing below means that you have received and understand this notice. You may also receive a copy.I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.Patient Signature* Reset signature Signature locked. Reset to sign again Responsible Party Signature* Reset signature Signature locked. Reset to sign again Today's Date MM slash DD slash YYYY
