Insurance Authorization Form

PATIENT FINANCIAL RESPONSIBILITY FORM (Advance Beneficiary Notice – ABN)

Note: You need to make a choice about receiving these health care services.

Your insurance may not pay for the service(s) that are listed below. Your insurance only pays for covered items and services when its rules are met, for example obtaining appropriate referrals from your primary care physician. The fact that your insurance may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it.

SERVICES: Evaluations, Procedures, and other Treatment – All Services Rendered

POTENTIAL REASONS FOR INSURANCE DENIALS

• Trinity Pain Center is not a participating “In-Network” provider with your insurance carrier
• Failure to obtain referral from your primary care physician, if required
• Non-compliance with insurance company’s recommended and/or approved course of treatment
• Deemed medically unnecessary by insurance company

The purpose of this form is to help you make an informed choice about whether or not you want these services, knowing that you may have to pay for them yourself. Before you make a decision about your options, you should read this entire notice.

• Ask us to explain, if you don’t understand why your insurance may not pay.
• Ask us how much these items or services will cost you (varies, depending on necessary treatment).

NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our offices. If a claim is submitted to your insurance, your health information on this form may be shared with your insurance.