Advance Beneficiary Notice
West Cary Psychiatry (WCP) offers computerized cognitive testing. While some insurance plans cover this service, some do not. Every effort will be made by WCP to ascertain coverage of these services before the time of my appointment, but the insurance confirmation is not a guarantee of coverage. Payment is ultimately the patient’s responsibility. If my insurance does not cover computerized cognitive testing, I, as the patient, will have to pay. Insurance does not cover all services, even some that I and/or my health care provider have good reason to think I need.
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Choose and option below regarding the computerized cognitive testing
*
Option 1: I want the computerized cognitive testing. I may asked to be paid at the time of service, but I also want my insurance to be billed for an official decision on payment, which is sent to me as an Explanation of Benefits (EOB) from my insurance company. I understand that if my insurance denies coverage of these services, I am responsible for payment, but I can appeal to my insurance by following the directions on the EOB. If my insurance does cover these services, WCP will refund any payments, less copays/coinsurance or deductibles.
Option 2: I want the computerized cognitive testing, but I do not want my insurance billed. WCP will be paid at the time of service, since I am responsible for the payment. I cannot appeal my insurance company if they are not billed.
Option 3: I do not want the computerized cognitive testing. I understand that with this choice I am not responsible for payment, and I cannot appeal to see if my insurance would cover these services.
Patient Agreement to Terms
This notice gives the opinion of WCP and is not an official insurance decision. If I have questions on this notice or insurance billing, I can call my insurance at the number listed on the back of my insurance car. Signing below means that I have read and understand this notice, and that I agree to the terms. I may ask to receive a copy.
Signature
*
Date of Signature
*
-
Month
-
Day
Year
Submit
Submit
Should be Empty: