UAB Home Infusion Therapy |
Main:( 866) 759-3120 |
Name: |
601 19 th St South |
Local: 205-209-3456 |
DOB: |
4 th Floor Quarterback Tower Suite 440E |
Fax: 205-438-9123 |
MR # |
Birmingham, AL 35249 |
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Date:
Financial Responsibility Acknowledgement THIS IS NOT A BILL
Patient Account # Patient Name: Primary Insurance:
Your insurance carrier( s) indicated above has advised us of general coverage information regarding your insurance benefits as related to the following estimated therapy cost:
Therapy( s): Estimated Duration:
Estimated Total Cost for medications, supplies & DME: $ 0 per day( Charges may vary according to use)
Per verification with your insurance company today, you have a $_ deductible then your policy pays _% of the supply charges up to a $ _ Out of Pocket then pays _%. You have met $_ towards your deductible and $_ towards your out of pocket.
Your total estimated amount you will be responsible for per week is: $ 0.
We cannot guarantee the amounts quoted above until your insurance company processes our claims. The amount owed is determined by your benefits at the time your insurance processes the claim.
Please review the insurance information in this letter. If the information is incorrect, or any changes in your insurance coverage occur, please notify our office immediately. You will remain responsible for any payment due as a result of changes in your insurance coverage for items and services provided to you that are not covered by your insurance carrier.
Please keep in mind that health insurance is designed to reimburse you for fees you have paid for services rendered and is not a substitute for your payment obligations. As a courtesy, we will submit insurance claims to your insurance carrier on your behalf. Nevertheless, you remain responsible for paying any amounts that are not covered or paid for by your insurance carrier.
If you have questions about this letter, your insurance coverage, or the cost and duration of your therapy, please feel free to call us at the number below between the hours of 7:30am and 4:00pm CST.
As a UAB Home Infusion Therapy patient, it is your responsibility to sign all delivery slips that accompany your deliveries and to sign your patient consent and assignment of benefits.
Sincerely, UAB Home Infusion Therapy Toll Free:( 866) 759-3120
18 UAB Home Infusion Therapy