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Telehealth Form

  • A. Notifier: Premier Eye Center
  • 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.
  • 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
  • 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 notice
  • Patient / Parent or Guardian
  • Date Format: MM slash DD slash YYYY