Advance Beneficiary Notice Of Noncoverage (Abn), Self Pay Notice Forms (Page 4 of 4) in pdf

Advance Beneficiary Notice Of Noncoverage (Abn), Self Pay Notice Forms Page 4

 CoxHealth Home Support

2224 W. Sunset

804 E. Hwy 60

1336 S. Sam Houston Blvd.

Springfield, MO 65807

Monett, MO 65708

Houston, MO 65483

417/269-3600

417/236-2490

417/967-5671

Self Pay Notice

Patient’s Name:

DOB:

We expect that

will not pay for the item(s) or

service(s) that are described below and therefore, your insurance will not be billed.

Item(s) or service(s)

Reasons insurance will not pay

Estimated cost

 Insurance coverage criteria was not met.

Explanation:

 It is after normal business hours and we are unable to verify

that your insurance’s coverage criterion has been met or we

are unable to obtain pre-certification. If we determine the

coverage criteria for your insurance has been met, we will bill

your insurance for the item(s) or service.

The estimated cost is based on current information and circumstances. Your final financial responsibility may vary from

this estimate.

By signing below, I acknowledge and understand that I am fully responsible for payment for these items and/or services.

Patient’s signature

Date

7/10

Rev 10/04/2011

Advance Beneficiary Notice Of Noncoverage (Abn), Self Pay Notice Forms Page 4