Advance Patient Notice

Advance Patient Notice
Dear Patient,

The purpose of this document is to help you understand your responsibilities regarding your insurance coverage, eligibility and payment responsibilities.

It has been identified that you have insurance that Alliance Obstetrics & Gynecology is considered out-of-network with. At this time, Alliance does not "accept assignment" with your plan, which means that there may be a difference between what your insurance will cover and the cost of our services. Please be advised that you will be responsible for any balance due over the allowed amount processed by your insurance.
Patient Name:*
Patient Date of Birth:*

MonthDayYear
Date
I am enrolled in the following insurance:*

ApostropheQuantum HST/KindercareEmployee Benefits LogisticsOther *
* If Other, type of insurance:
By placing my signature on this waiver form below, I ackowledge the following:
- I am aware that Alliance Obstetrics & Gynecology does not accept assignment with my insurance.
- I understand that I will be responsible for additional costs over the allowed amount for all services provided by Alliance Obstetrics & Gynecology.
- I am voluntarily choosing on behalf of myself or my child/legal guardian to obtain the service from the non-participating physician.
- I understand that if I choose to have my care with this practice, Alliance Obstetrics & Gynecology will file my claim for the services provided to my insurance company and that I will be required to pay for any balances above the allowed amount.
By signing this document, the patient or patient's representative authorizes Alliance Obstetrics & Gynecology and/or collection service providers to use all information provided by the patient or representative for contact. Absence of a signature does not invalidate this notification.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: