PERSONAL & CONFIDENTIAL
(Please provide patient or legal guardian with a completed copy and retain original.)
Advance Patient Notification Form
Your physician is arranging for a non-participating provider to be involved in your care. You have the right to arrange for services to be rendered by a participating provider in order to obtain full benefits under your contract or certificate of coverage. If you have any questions or would like to locate an in-network provider to provide the service or procedure, please contact Empire Customer Service at the telephone number listed on the back of your Empire identification card.
To be completed by the referring physician:
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Patient Name Empire Member ID Number
______
Participating physician making the referral NPI
______
Non-participating provider to be involved in the Specialty
patient’s care
______
Type of service/procedure (i.e., anesthesia, surgical Date of scheduled service or procedure
assistant, lab, DME, home infusions, specialty drugs, etc.)
Total Estimated Cost/Charge of the Service or Procedure
(MUST BE COMPLETED BY THE REFERRING PHYICIAN):
$100 or Less $100- $1,000 $1,000- $5,000 $5,000- $10,000 $10,000 or more
Reason for referral to the non-participating provider:
Member convenience/Provider convenience
Other (please describe) ______
To be completed by the patient or the patient’s legal guardian:
By placing my signature on this waiver form below, I acknowledge the following:
1. I am aware that the non-participating provider that has been recommended above to perform the procedure or service does not participate with Empire.
2. I was given adequate opportunity to contact Empire for names of participating providers that could provide the recommended service or procedure.
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3. I understand that I will be responsible for either the total amount of the provider’s billed charge or difference between Empire’s reimbursement and the provider’s billed charge for all services provided to the patient by the non-participating provider, as may be permitted under my contract or certificate of coverage.
4. I understand that the non-participating provider is prohibited from waiving co-payments, deductibles, coinsurance or other member cost sharing amounts under my contract or certificate of coverage.
5. I am voluntarily choosing on behalf of myself or my child/legal guardian to obtain the service or procedure from the non-participating provider, and I will be responsible for payment.
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Print Patient Name
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Print Name of Parent or Legal Guardian
(If patient under age 18)
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Signature of Patient/Legal Guardian
______
Date
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