ADVANCE PROCEDURE BENEFICIARY NOTICE

We expect that your insurance may NOT pay for certain items or services due to your health plan limitations. Insurance companies only pay for covered items and services when their rules are met. A few procedures done in this office for diagnostic purposes are not paid for by insurance under your co-pay or office visit charge. The procedures are considered SURGICAL based on the AMA’s (American Medical Association) classification. Many times these services are paid at a % only after your deductible has been met.

The fact that your insurance may NOT pay for a particular item or service does not mean that you should not receive it. There is probably a good reason the service is being recommended. Many such procedures done in this office involve scopes needed to view areas of the ear, nose and throat. Scope procedures allow the physician to diagnosis problems, rule out masses / obstruction, and treat the patient accordingly.

The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself.

* Not knowing what may be ordered for each visit / patient prior to your appointment we are unable to
call your insurance to verify your particular benefits in advance.

* Scopes can range from $100 to $400 in price.

I want to receive these items or services.
I understand that my insurance may not pay for certain items or services I receive in this office.
Please submit a claim to my insurance company. I understand that you may bill me for items or
services over and beyond my co-pay. I agree to be personally and fully responsible for payment.
Payments are acceptable.

I have decided not to receive these items or services.
I will not receive these items or services. I understand my decision is against medical advice and
will make diagnosing and treatment of my problem difficult and possibly unsuccessful.

NOTE: Your health information will be kept confidential. Any information that we collect about you will be kept confidential in our office. Your health information may be shared with your insurance company if a claim is submitted.