Telehealth Form A. Notifier: Premier Eye CenterB. Patient Name* First Last C. Chart Number*Advance Beneficiary Notice of Noncoverage (ABN) NOTE: The doctor has ordered specific services that may not be covered under insurance. If insurance doesn’t pay for the services listed (Box D) below, you may have an out of pocket expense. D. Services Ordered by Doctor:* TELE Health Visit-$130.00 E. Reason Insurance May Not Pay*Not covered under the planDeductable not metProvider out of NetworkPatient is electing out of pocketF. Estimated out of pocket cost*WHAT YOU NEED TO DO NOW Read this notice, so you can make an informed decision about your care. Ask us any questions that you may have after you finish reading Choose an option below to receive the testing listed above (Box D) listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have G. OPTIONS* OPTION 1. I want to receive the services listed in Box D. I consent to payment now, and I also want insurance billed for an official decision on payment. Official payment information will be sent to me on an Insurance Summary Notice. I understand that if insurance doesn’t pay, I am responsible for payment, but I can appeal to insurance by following the directions on the MSN. If Insurance does pay, you will refund any payments I made to you, less co-pays or deductibles. OPTION 2. I want to receive the services listed in Box D, but do not bill Insurance. You may ask to be paid now as I am responsible for payment. I cannot appeal if Insurance is not billed. This notice gives our opinion, not an official Insurance decision. If you have other questions on this notice or Insurance billing, you may be directed to speak with our Insurance Coordinator. Signing below means that you have received and understand this noticeI. Signature*Patient / Parent or GuardianJ. Date:* MM slash DD slash YYYY
