Patient Responsibility Form

A member may be responsible for services rendered without a valid referral, for non covered services, out of network services, or services that BlueShield of Northeastern New York determines in advance are not medically necessary.

If you have a managed care (HMO) contract without out-of-network benefits, the following applies:

  • Provider Office Visits: If you visit a provider's office without your referral authorization and the referral cannot be verified, you are financially responsible for today's visit. You may not submit the bill to BlueShield of Northeastern New York for reimbursement.
  • Lab Services: Please use your physician’s office, a participating commercial lab or specific hospitals participating as a lab vendor for BlueShield of Northeastern New York. You will be financially responsible for the cost of lab services provided at any other location and you cannot submit the bill to BlueShield of Northeastern New York for reimbursement.

If you have a managed care (HMO) contract with out-of-network benefits, the following applies:

  • Provider Office Visits: To be eligible for the highest level of benefits (in-network), a referral to a network provider is required. If you visit a provider's office without your referral authorization and the referral cannot be verified, or if you seek services from an out-of-network provider, the services are considered out-of-network. You are financially responsible for the coinsurance and any amount that is applied to the deductible for today's visit.
  • Laboratory Services: The highest level of benefits (in-network) for lab services ordered by your physician are available from your physician’s office, a participating commercial lab or specific hospitals participating as a lab vendor for BlueShield of Northeastern New York. If you receive lab services at any other site, the services are considered out-of-network. You are financially responsible for the coinsurance and any amount that is applied to the deductible for today's visit.
  • Medically Necessary Services: A provider may seek payment from you for any services BlueShield of Northeastern New York determines in advance are not medically necessary.

I have read and understand BlueShield of Northeastern New York’s policy on referrals and medical necessity.

Community Blue/Traditional Blue/Medicare Advantage: I understand that these services cannot be billed to BlueShield of Northeastern New York and that I am financially responsible for today's visit.

Out of Network: I understand that these services are considered "out-of-network" and that I am responsible for the coinsurance and any amount that is applied to the deductible.

Medically Necessary: I understand that these services have been determined by BlueShield of Northeastern New York to be not medically necessary and that I am financially responsible.

If you have questions or need to verify a referral, you may contact the BlueShield Member Service department by calling the toll free Customer Service number on the back of your identification card.

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Signature (Patient, Parent or Guardian)Date