will not pay for the item(s) or service(s) that are described below. Your medical insurance does pay for all of your healthcare cost, only covered benefits. When you receive an item or service that is not covered benefit, you are responsible to pay for it, personally or through any other insurance that you may have. The fact that your medical insurance may not pay for a particualr item or service does not mean that you should not recieve it. There may be a good reason your doctor recommended it.
The purpose of this form is to help you make an informed choice about whether or not you want to receive these item(s) or service(s), knowing that you will have to pay for them yourself. Before you make any decision about your options, you should read this entire notice carefully.
- Ask us to explain, if you do not understand why your medical insurance will not pay.
- Ask us how much these item(s) or service(s) wil cost you (Estimated Cost:$________)
I understand I am responsible for all the charges not covered by my medical insurance and i accept full responsibility to pay for item(s) or service(s) rendered to me.