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 Registration Date: ___________________ Patient Name: __________________________________________________________________ ADVANCE BENEFICIARY NOTICE (ABN) FOR NON-­‐COVERED SERVICES NOTE: You need to make a choice about receiving these health care services. I accept that my insurance may not pay for the service(s) listed below, due to the fact that this procedure may not be a covered benefit. The fact that my insurance may not pay for a particular service does not mean that I should not receive it. Service(s) Code(s): Fees: The purpose of this form is to help you make an informed choice about whether or not you want to receive these services, knowing that you will have to pay for them yourself. Before you make any decision about your option, you should read this entire notice carefully. Ask us to explain, if you do not understand why your insurance company will not pay. Please also check with your insurance company to verify benefits. Ask us how much these services will cost you approximately. Fees are subject to change without notice. PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN AND DATE YOUR CHOICE.
Ο OPTION 1. YES. I WANT TO RECEIVE THESE SERVICES. I understand that my insurance may not pay for these services. I will be responsible to pay for the service(s) prior to them being rendered. Ο OPTION 2. NO. I DO NOT WANT TO RECEIVE THESE SERVICES. __________________ ___________________________________________________ DATE Signature of the patient/person acting on the patients’ behalf HackensackUMG | FACULTY PRACTICE PLAN
ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY
Our physicians and Staff are dedicated to assisting you to make sure that your health insurance has all of
the information necessary to reimburse for all covered services. Your health insurance may not pay for
all of your health care costs; you, your employer and your insurance company largely determine your
health benefits. Health insurance only pays for covered items and services when their rules are met.
INSURANCE COVERAGE
 It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and
limitations as well as authorization requirements. This information is furnished by the insurance
carrier.
 We attempt to verify that your coverage is valid at the time of your visit. However, if your
coverage is not in effect at the time of your visit, you will be responsible for payment.
INSURANCE CHANGES
 If you have had any changes in your insurance coverage, please notify us. Failure to do so may
result in a claim denial and you will be billed.
CO-PAYMENTS, CO-INSURANCE AND DEDUCTIBLES
 Co-insurance and co-payments are the patient’s/guarantor’s responsibility. Co-payments are
due at the time of the visit.
 Deductibles are the patient’s/guarantor’s responsibility. The deductible is determined by the
contract you have with your health insurance carrier.
REFERRALS
 If your plan requires, it is your responsibility to obtain referrals from your Primary Physician
prior to your visit. If you wish to be seen without the referral, payment is due at the time of
visit.
INSURANCE REQUESTS
 You are responsible for responding to insurance company requests for further information.
INSURANCE PAYMENTS
 Any insurance payments sent to you should be forwarded to our Billing Office with a copy of the
explanation of benefits (EOB) received.
I have read and understand the terms of this Financial Responsibility form.
Patient/Guarantor Signature
Date
Patient Name:______________________________
Account Number:_________________
One copy returned to the patient/guarantor and one copy filed in the patient’s medical record
1/30/2012
CONFIRMACIÓN DE RESPONSABILIDAD FINANCIERA
Nuestros médicos y personal están dedicados a ayudarle para garantizar que su seguro medico tenga
toda la información necesaria para rembolsar todos los servicios cubiertos. Es posible que su seguro
medico no cubra todos los costos de su cuidado de salud; usted, su empleador y su compañía
aseguradora en gran parte determinan sus beneficios de salud. El seguro medico solo paga renglones y
servicios cubiertos cuando se cumplen sus requisitos.
COBERTURA DEL SEGURO
 Es responsabilidad de usted conocer la cobertura de su seguro, disposiciones de la póliza,
exclusiones y limitaciones, así como los requisitos de autorización. Esta información ex
suministrada por su compañía aseguradora.
 Tratamos de verificar que su cobertura sea valida para el momento de su consulta. Sin
embargo, si su cobertura no esta vigente para el momento de su consulta, usted será
responsable del pago.
CAMBIOS DEL SEGURO
 Si ha habido algún cambio en la cobertura de su seguro, le agradecemos que nos lo notifique.
No hacerlo podría dar lugar a que el reclamo sea rechazado y se le facture a usted.
COPAGOS, COASEGURO Y DEDUCCIONES
 El coaseguro y los copagos son responsabilidad del paciente/fiador. Los copagos deben pagarse
en el momento de la consulta.
 Los deducibles son responsabilidad del paciente/fiador. El deducible se establece según el
contrato que usted tenga con su compañía aseguradora.
REFERIDOS
 Si su plan los exige, es responsabilidad de usted obtener los referidos de su medico de atención
primaria antes de su consulta. Si desea ser atendido sin tener el referido, deberá hacer el pago
al momento de la consulta.
REQUISITOS DEL SEGURO
 Usted es responsable de dar respuesta a las solicitudes de información adicional que haga la
compañía aseguradora.
PAGOS DEL SEGURO
 Todo pago del seguro que usted reciba deberá reenviarlo a nuestra oficina de facturación con
una copia de la explicación de beneficios (EOB) recibida.
He leído y entiendo los términos de este formulario/de Responsabilidad Financiera.
Firma del paciente/fiador
Fecha
Nombre del paciente:____________________________
Numero de cuenta:_________________
Una copia para el paciente/fiador y una copia archivada en el expediente medico del paciente
1/30/2012