Patient Billing Acknowledgement Form For Non-Covered Services including Maintenance/Wellness and Elective Services

Confusing as it may sound, the standard ABN form (Advanced Beneficiary Notice) is NOT needed for services that MEDICARE never covers.  Rather it is used to put your patient on notice that a service MAY NOT be covered.

If you are offering services that you know Medicare, or any other plan will not, this 2-page form (one for services, one for products) spells this out so you have a signed attestation that you have notified the patient that this is a non-covered service that they will pay for privately without any submission to any carrier for potential partial or full reimbursement.

Downloadable, editable and attorney reviewed.

Terms and Conditions

By purchasing this form, we are granting you the non-exclusive use of this material. You may not re-sell or otherwise transfer the material to another therapist outside of your own practice. By virtue of submitting payment for the course, you hereby are agreeing to the following:

  1. Digital Product Usage -After purchasing the form, you will be given immediate access to it and will have lifetime access to use it for your own personal use and business use.2. Refund Policy- Due to the nature of the form being immediately accessible upon purchasing, no refunds of any fees or other amounts paid by you in connection with the course will be allowed under any circumstances.

    3. Warranties and Liability -Every effort is made to ensure that the form is accurate and fit for the use by purchasers However, we take no responsibility whatsoever for the suitability of the form and provide no warranties as to the function or use of the form, whether express, implied or statutory, including without limitation any warranties of merchantability or fitness for particular purpose. You agree to indemnify the creator against all liabilities, claims, demands, expenses, actions, costs, damages, or loss arising out of any breach of these terms and conditions. The creator shall not be liable to you or any third party for consequential, indirect, special or exemplary damages including but not limited to damages for loss of profits, business or anticipated benefits whether arising under tort, contract, negligence or otherwise whether or not foreseen, reasonably foreseeable or advised of the possibility of such damages.

By virtue of submitting payment for the form, the purchaser agrees to abide by the above terms and conditions