ABN Form – Houston Neuropsychology Associates

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If your insurance company does not pay for the psychological evaluation you or your healthcare provider have requested, you may have to pay. Insurance companies do not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect that your insurance company may not pay for the psychological evaluation requested.

This service is being provided for medical necessity. The patient has been informed that Houston Neuropsychology Associates (HNA) is not contracted with his/her insurance plan at this time. The patient has elected to pay out of pocket.

Next Steps:

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 psychological evaluation.

Please select one of the following options.(Required)

I want the psychological evaluation requested. You may ask to be paid now, but I also want my insurance company billed for an official decision on payment. I understand that if my insurance company does not pay, I am responsible for payment, but I can appeal to them. If my insurance company does pay, you will refund any payments I made to you, less copays or deductibles.

I want the psychological evaluation requested, but do not bill my insurance company. You may ask to be paid now as I am responsible for payment. I cannot appeal if my insurance company is not billed.

I do not want the psychological evaluation I originally requested.

This notice gives our opinion, not an official insurance company decision. If you have questions about this notice or billing, please contact your insurance company.

Signing below means that you have received and understand this notice. You will also receive a copy by email.

Patient's Name(Required)

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Date of Signature(Required)

Email(Required)

Please provide the email address to which we will send a copy of your form submission.