PATIENT_Telehealth Financial Consent/ABN

Patient Name*

First NameLast Name

Date of Birth*

DOB

Phone Number*

Please enter a valid phone number.

Patient Email*

Confirmation Emailexample@example.com

Fee Schedule Price(s):
• 99213/G2211: $399.00
• 99214/G2211: $521.00
• 99215/G2211: $690.00

Estimated Price is for the telehealth visit only.
Any additional labs/services/procedures are not included.
PIF Discount [50%] of estimated price applies only if PAID IN FULL on/or before the date of the appointment.
Make sure to call the office receptionist immediately after your telehealth appointment is completed to make payment.
Failure to pay on the same day will result in having to pay the visit charge at 100% without a discount.
Optional Credit Card on File form is available to automatically pay after visit is completed so PIF discount is utilized.

I, above-mentioned patient name, understand that the services and/or supplies listed above may not be covered by my health policy/plan.

They may be considered ineligible for benefits due to the following: (including but not limited to)

• Services and/or supplies may be non-covered (frequency limits, diagnosis requirements, exceeds cap)
• Services and/or supplies may be excluded by health policy/plan
• Services and/or supplies not medically reasonable and necessary.
• Prior Authorization /Certification/Criteria or other requirements have not been met.
• Considered investigational/experimental/unsafe/ineffective by my health policy/plan.

[X] I want the TELEHEALTH VISIT listed above. I understand I will have to pay now, but I also want my insurance billed for an official decision on payment, which is sent to me as an Explanation of Benefits. I understand that if my insurance doesn’t pay, I am responsible for payment, but I can appeal to my insurance company. Refunds will be made accordingly if insurance makes a payment. I understand that my health insurance coverage has certain restrictions and limitations, such as authorization requirements, non-covered services and/or supplies. Because I have chosen to obtain the services and/or supplies listed below, I agree to be financially responsible for any and all related charges if they are not covered by my insurance. This consent is ongoing for this service and all future services unless a change is made in writing.

Advance Beneficiary Notice of Non-coverage (ABN)

A. Notifier: Enhanced Wellness of Oak Grove PLLC, 56 98 Place Blvd, Hattiesburg, MS 39402 (601) 264-7286 – Betty L Ryba, NP

B. Patient Name: ________________________________________ C. Patient Account Number: _____________

If Medicare doesn’t pay for D. Telehealth Office Visit below, you may have to pay.
Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. Telehealth Office Visit below.

D. Telehealth Office Visit 99213: $299.00 or 99214: $421.00 or 99215: $590.00 and G2211: $100.00

E. Reason Medicare May Not Pay: Non-Covered; Expiration of temporary federal funding: This change means that Medicare beneficiaries will no longer be able to receive telehealth services unless current criteria is met (i.e.: FQHC/RHC distant site)

F. Estimated Cost: Depends on OV Service level. See estimated per CPT code in section “D”
WHAT YOU NEED TO DO NOW:
Read this notice, so you can make an informed decision about your care; Ask us any questions that you may have after you finish reading; Choose an option below about whether to receive the D.Telehealth Office Visit listed above. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.

G. OPTIONS: Check only one box. We cannot choose a box for you.
[ X ] OPTION 1. I want the [D.Telehealth Office Visit] listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
□ OPTION 2. I want the [D.Telehealth Office Visit] listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.
□ OPTION 3. I don’t want the [D.Telehealth Office Visit] listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.

H. Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You may ask to receive a copy.

I. Patient Signature: [see form signature] J. Date: [see form date]
You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about- us/accessibility-nondiscrimination-notice.

Today's Signature Date*

Today's Date

Signature*

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law.

Financial Responsibility: I understand that I am responsible for all charges not paid by my insurance plan except those amounts that the Clinic is contractually obligated to write off. I understand that I am responsible for all non-covered services and by signing this form I acknowledge I have been made aware of my obligation prior to receiving such services. I understand that if I do not pay for the charges for which I am responsible the clinic may turn my account over to a collection agency. I understand that should my account be turned over to a collection agency I may be charged a collection fee, not to exceed 25% of my account, and I accept these fees charged by the Clinic as a legal and lawful debt and agree to pay such fee if charged.

Telehealth ABN/Financial Consent Form

Advance Beneficiary Notice of Non-coverage (ABN)

Credit Card Authorization Form