Beyfortus Payment Form for Commerically-insured Patients

Patient Name*

First NameLast Name

Patient's Date of Birth*

Date

Current insurance company: *

Please note: Ambetter and AHCCCS plans are not eligible for Beyfortus in our clinic given our allotment.

YesNo

Here is the CDC information sheet on Beyfortus that is required upon administration of this injection. Also see our website for FAQs. Thank you!

Beyfortus CDC Information Sheet

Beyfortus Payment Policy

As the parent/guardian of the patient listed above, I desire the Beyfortus Monoclonal Antibody injection for my child. I understand that at this time it appears my insurance WILL cover this injection. All insurances have been covering this vaccine this season; however, coverage details may vary by plan. The total amount billed to insurance will be approximately $650 (two charges, one for the injection itself and one for the administration of that shot). This early eligibility determination is not a guarantee of payment from insurance. If my insurance company DENIES payment of the injection as a non-covered service or because my insurance was inactive on the date of service, I understand that I will be personally responsible for payment for this visit for this service. Should my insurance not cover the service at all, I understand that I will owe $600 due our prompt pay discount. Should my insurance apply any or all of this visit to my deductible or any other cost-sharing arrangement (copays, co-insurance, etc.), I understand that I will be responsible for whatever that amount is and that Tanque Verde Pediatrics cannot change this amount as this is determined by my insurance company and coverage with them.

Your signature below demonstrates that you agree to this policy. Again, we will first bill your insurance company. If this is not a covered service on your plan, or if you have not added your child to your insurance, your card will be charged. If your insurance company retroactively covers this shot at a later date, we will rebill them, and if they cover it, we will refund your charge.

IF YOU HAD THE ABRYSVO (PFIZER'S RSV) VACCINE WHILE PREGNANT, YOUR CHILD IS PROTECTED AND DOES NOT NEED BEYFORTUS.

I UNDERSTAND THAT IF I AM ELIGIBLE TO RECEIVE VFC SHOTS (i.e., I have no insurance or I am eligible for Medicaid), I NEED TO NOTIFY THE OFFICE IMMEDIATELY UPON RECEIPT OF THIS FORM THAT THERE IS AN ISSUE WITH MY INSURANCE. TVP IS ONLY ABLE TO PROVIDE THIS SHOT TO FAMILIES WITH KNOWN COMMERCIAL INSURANCE SINCE THE STATE HAS NOT ALLOTTED US SUPPLIES FOR PEOPLE WITHOUT INSURANCE.

Please type the name of the responsible party (parent/guardian) for medical payment and decision-making on the Beyfortus appointment date: *

First NameLast Name

Signature of above-named: *

Today's date:

Date