Medicare ABN

3rd Party Advanced Beneficiary Notice of Non-coverage
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This form is to inform you of potential services and/or materials that your 3rd party insurance may not pay. If your 3rd party insurance doesn't pay for the items checked or listed in the box below, the services and/or materials are your financial responsibility. While your 3rd party insurance doesn't cover all services and/or materials, the items checked or listed in the box below are important for the health or your eyes.
The following services and/or materials are recommended for you, however, we expect your 3rd party insurance may not pay:

Comprehensive Eye Exam (price varies)Refraction 92015: $39.00Pachymetry 76514: $16.00Retinal Screening: $44.00Retinal Photos 92250: $82.00Visual Fields 92083: $101.00Gonioscopy 92020: $46.00OCT 92135: $98.00Vision Therapy: $632.00/blockNew Patient Vision Therapy Consultation: $241.00Intra Vision Therapy Consultation: $220.00Vision and Learning Consultation: $280.00Contact Lenses (price varies)Contact Lens services (price varies)Eyewear lenses (price varies)Eyewear frames (price varies)Emergency appointment (Sunday/Holidays) 99050: $125.00Emergency appointment (After Hours) 99051: $75.00Emergency appointment (Near Closing) 99058: $35.00Other
Reason your 3rd Party Insurance May Not Pay:

It is not covered in your contractNo documentation of medical problemIt is a screening testThe frequency limit is exceededNo proof of coverageOther
Total Estimated Cost:
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 checked items listed in the first box above.
Please check only one option. We cannot choose an option for you.

Option 1: I would like to proceed with the services and/or materials listed above. You may ask to be paid now, but I also want my 3rd party insurance to be billed for an official decision on payment. I understand that if my 3rd party insurance doesn't pay, I am responsible for payment, but I can appeal to my 3rd party insurance. If my 3rd party insurance does pay, you will refund any payments I made to you, less co-pays and deductibles.Option 2: I would like to proceed with the services and/or materials listed above, but do not bill my 3rd party insurance. You may ask to be paid now as I am responsible for payment. I cannot appeal if my 3rd party insurance is not billed.Option 3: I don't want to proceed with the services and/or materials listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to my 3rd party insurance for payment.
This notice gives our medical recommendations, but it is not an official decision from your 3rd party insurance. If you have other questions on this notice or medical insurance billing, please contact your 3rd party insurance.

Signing below means that you have received and understand this notice. Please let us know if you would like a copy.
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3rd Party Advanced Beneficiary Notice of Non-coverage