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. 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, charged to a credit card that we require at the time of the vaccine. 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.
We will need a credit card on file with us prior to giving this shot so that if your insurance does not cover it, you agree to accept responsibility for the cost. 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.
I UNDERSTAND THAT IF I AM ELIGIBLE TO RECEIVE VFC SHOTS (ie. 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 PROVIDING THIS FORM TO FAMILIES WITH KNOWN COMMERICAL INSURANCE.