ADVANCED BENEFICIARY NOTICE (ABN) AND MEMBER (PATIENT) FINANCIAL RESPONSIBILITY AGREEMENTAdvanced Beneficiary Notice and Member Financial Responsibility Agreement • April 18th, 2014
NOTICE TO MEMBER: Your health care benefit plan may prohibit participating health care professionals and/or facilities such as SunMED Medical/A Personal Touch Boutiques (“Providers”) from charging members such as you for any service, product or upgrade that is deemed not medically necessary or non-covered for other reasons, unless the Member (such as you) specifically requests such service or product and agrees in writing to be financially responsible for it. This waiver form may be used to document your agreement to be financially responsible for such services and products. Your health care benefit plan may require that this document be executed prior to the delivery of any non-medically necessary or non-covered service or product.
