Abn Form Commercial Insurance – Fill Out and Use This PDF

SIGNATURE ON FILE/ABN FORM

I request that payment of authorized Medical/Medicare Insurance benefits be made on behalf of (patient’s name)

_______________________________, for services furnished to me by Dr. Latham/Dr. Granado-Chaney. I authorize any

holder of medical information about me, to be released to the Centers for Medicare and Medicaid Services and its agents. Including any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health information is indicated in Item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Dr Latham/Dr. Granado-Chaney accepts the charge determination of the Medical/Medicare Insurance carrier as the full charge, and the patient is responsible for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determination of the insurance carrier.

VISION INSURANCE

Insured Name(Mr./Mrs./Ms.) ________________________________ Relationship To Patient _________________________________

Insured’s Employer _______________________________________ Insured Date of Birth ___________________________________

Insured SS# _____________________________________________ Name of Ins. Carrier ____________________________________

Member ID# ____________________________________________ Group # ______________________________________________

MEDICAL INSURANCE

Insured Name(Mr./Mrs./Ms.) ________________________________ Relationship To Patient _________________________________

Insured’s Employer________________________________________ Insured Date of Birth ___________________________________

Insured SS# _____________________________________________ Name of Ins. Carrier ____________________________________

Member ID# ____________________________________________ Group # ______________________________________________

INSURANCE REQUIREMENTS

We will be happy to file your insurance claim forms or to take assignment of your vision and/or medical benefits as designated by your insurance company. We are happy to provide this service without any additional charge to you. We will do all that we can to help you receive the maximum benefits. However it is your responsibility to know your insurance plan’s requirements and benefits and to notify the staff at Harwood Vision Clinic. Lack of proper identification could result in you being responsible for all charges, and insurance claims will not be submitted after services have been rendered. We will gladly supply you the proper paperwork for you to submit your claim.

We go to great lengths to verify the amount and type of coverage you are allowed under your plan. We can quote your estimated coverage, however final determination of benefits will not occur until the insurance company receives your claim. In the event the plan sponsor determines that you are not eligible at the time of service, or determines that you are eligible for a reduced benefit level, or applies the charges to the deductible, by signing this statement you agree to be financially responsible for any and all charges incurred by you and not paid by the plan sponsor. Any balance on your account is due within 30 days. If not, a monthly finance charge of 18% will apply.

PRIVACY PRACTICES AND FINANCIAL RESPONSIBILITY

I acknowledge that a copy of Harwood Vision Clinic’s Privacy Practices has been made available to me. I agree to be financially responsible for any fees incurred as a result of today’s services and/or materials provided, including those not covered by insurance.

Signature ___________________________________________________ Date _________________________________________