Patient Financial Responsibility and Non-Coverage Acknowledgment Form

Patient Financial Responsibility and Non-Coverage Acknowledgment Form
Name

First NameMiddle NameLast Name
Date of birth

MonthDayYear
MM-DD-YYYY
Purpose of this Form

Your insurance plan may not cover all medical services, tests, or treatments ordered by your healthcare provider. This form ensures transparency and helps you understand your potential financial responsibility.

Potentially Non-Covered Service(s)

Description of Service: Home PSG.

Estimated Cost (if known): $999

Patient Acknowledgment

1. The service(s) listed above is not a covered benefit under my policy.
2. I agree to be personally responsible for all associated charges.
3. I have been informed that I may choose not to receive the service(s) listed above.
4. I have had an opportunity to ask questions about this and understand my options.
OPTIONS: CHECK ONLY ONE BOX.

OPTION 1. I choose to receive the above service(s) and accept financial responsibility.OPTION 2. I decline the above service(s).
Patient Signature:
Date of Patient Signature:

MonthDayYear
Date
Practice Information

Telemedora, PC

HIPAA Notice: All patient information collected on this form is protected under HIPAA and will be used only for billing and documentation purposes.
Should be Empty: