Pharmacy & Abn - Eyexcel
ADVERTISEMENT
1Pharmacy
IF the doctor needs to write you a prescription, we will send the Rx to your
pharmacy electronically or call it in for you. We need your pharmacy preference.
Name of Pharmacy: _________________________ Address: __________________________________
Phone: ________________ Special Instructions: ____________________________________________
Second Pharmacy: __________________________ Address: __________________________________
Phone: ________________ Special Instructions: ____________________________________________
Advance Beneficiary Notice of Non-Coverage (ABN)
NOTE: If Medicare or your medical insurance does not pay for certain procedures listed below, you may
have to pay. Insurance does not pay for everything, even some care that you or your health care provider
have good reason to think you need. We expect that Medicare or insurance will not pay for the following:
Services
Reason Insurance May Not Pay:
Estimated
Cost
CPT code: 92015 Refraction
If your diagnosis is medical and your vision
$25.00
coverage doesn’t cover your medical exam,
(determines your eye glass or
contact prescription)
your insurance may cover the exam but not
the refraction. (considered routine vision)
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 about whether to receive the procedure recommended by the doctor.
Note: If you choose Option 1 or 2, we will help you to use any insurance that you have.
O
:
Check only one box. We cannot choose a box for you.
PTIONS
☐ OPTION 1. I want the procedure listed above IF recommended by the doctor. I may be asked to
pay now, but I also want Medicare or my insurance billed for an official decision on payment, which is
sent to me as an EOB (explanation of benefits). I understand that if insurance doesn’t pay, I am
responsible for payment. If money is collected and insurance does pay, a refund of any payments I
made, less co-pays or deductibles, will be returned to me or left as a credit on my account.
☐ OPTION 2. I want the recommended procedure, but do not bill my insurance. I will pay now as I am
responsible for payment. I cannot appeal if Medicare or my insurance is not billed.
☐ OPTION 3. I DON’T want the procedure if recommended or ordered by the doctor. I understand with
this choice I am not responsible for payment, and I cannot appeal to see if my insurance would pay.
This notice gives our opinion, not an official insurance decision. If you have other questions on this
notice or about insurance billing, please ask one of trained staff members or the administrator.
.
Signing below means that you have received and understand this notice. You may also request a copy
Signature:
Date:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7
minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection.
PO Box 12218
*
Knoxville, TN 37912
*
(865) 687-1232
*
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal