Iron IV Advance Beneficiary Notice of Non-coverage (ABN)

1

A. Notifier: Institute of Complementary Medicine

2

This signed Iron IV ABN supersedes any EOB that you receive from your insurance. If you choose to have the procedure billed to your insurance, you are responsible for the difference between what insurance pays and the total cost of the Iron IV. No insurance adjustment will be recognized.

If you would like to contact your insurance to see what they will pay, please give them this code: 96374. Be sure to inform them that you have signed an ABN for the procedure. Please remember: you are responsible for anything insurance does not pay.

3

I understand and agree to the Iron IV disclaimer* This field is required.You must agree to the disclaimer to be able to receive the procedure.

YESNO

4

You must agree to the Iron IV disclaimer in order to proceed.

5

B. Patient Name* This field is required.

First Name

Last Name

6

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If Insurance doesn’t pay for D. below, you may have to pay. Insurance does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Insurance may not pay for the D.

7

D.	E. Reason Insurance May Not Pay:	F. Estimated Cost
Single Infusion	Insurance may not cover an out-patient IV procedure	$200

8

WHAT YOU NEED TO DO NOW:

Read this notice, so you can make an informed decision about your care.
Ask us any questions that you may have after you finish reading.
Choose an option below about whether to receive the D. listed above.

9

G. Options: Check only one box. We cannot choose a box for you.* This field is required.

10

H. Addition Information:

This notice gives our opinion, not an official insurance decision. If you have other questions on this notice or insurance billing, call the number listed on your insurance card. Signing below means that you have received and understand this notice. You also will receive a copy.

11

I. Signature* This field is required.

12

J. Date:* This field is required.

Date