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. This early eligibility determination is not a guarantee of payment from insurance. If my insurance company DENIES payment of the injection for any reason I understand that I will be personally responsible for payment for this injection. Should my insurance not cover the service, I understand that I will be charged $600 (self-pay discount) to my credit card on file. 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 Roadrunner Pediatrics cannot change this amount as this is determined by my insurance company and coverage with them.
I agree to place a credit card on file with Roadrunner Pediatrics at the time of this visit. My insurance company will be billed for the injection, and if it is not covered, I agree to the charge as noted above. If my insurance company offers coverage at a later date or after appeal, I will be refunded.