3d Mammography Advance Beneficiary Form

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SOUTHTOWNS RADIOLOGY ASSOCIATES
Advance Beneficiary Notice
DATE:_____________ PATIENT:___________________________ INSURANCE:________________________________
You are receiving this Notice because your health insurance company may not pay for certain services or items from
Southtowns Radiology Associates, LLC., and you must decide whether or not to receive them.
You should:
Read this Notice carefully so you can make an informed decision about your care.
If you are uncertain or need more information, ask your Southtowns Radiology Associates, LLC. professional.
Decide whether or not you wish to receive these services or items, indicate your decision below, and sign and
date this form.
Services or Supplies
Why Insurance May Not Pay
Estimated Cost
Screening 3D
May not be a covered benefit of your insurance
$60.00
Tomosynthesis
policy at this time.
Mammogram
Diagnostic 3D
May be applied to the patient responsibility portion
$200.00
Tomosynthesis
of your insurance policy. (Example: your deductible,
Mammogram
coinsurance or copay)
(Check the correct choice)
_______ YES I want to receive these services or items. I acknowledge and agree that if my insurance company denied
payment in whole or in part, Southtowns Radiology Associates, LLC. will bill me for the unpaid portion and I will be
personally responsible for payment. If my insurance company ultimately pays for these services or items, Southtowns
Radiology Associates, LLC. will refund an appropriate portion of what I have paid. I will also be responsible for any
deductible, co-payment or other charge not covered by your health insurance.
_______ No I have decide not to receive these services or items. I understand that the fact that insurance will not pay
for these services or items does not mean that I should not receive them; however, I have made an informed decision
not to receive them.
By checking “YES” and signing this Notice, you agree to personally pay the cost of the services or items listed above if
your health insurance company denies coverage.
__________________
___________________________________________
(Date)
(Signature)

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