Advance Beneficiary Notice Morrow

User Manual: Advance-Beneficiary-Notice-Morrow

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ADVANCE BENEFICIARY NOTICE FORM
Pope Paul VI Institute Physicians, PC
6901 Mercy Road

Omaha, NE 68106

BEHAVIORAL HEALTH SERVICES
I, (Patient’s Name) __________________________________________ on (Date) ________________
understand that the following will apply and be enforced as long as I am a patient of
Dr. Kelly Morrow, Ph.D. at the Pope Paul VI Institute:
Most insurance companies have determined that the following procedures or services provided for you
by this office may be deemed “not medically necessary/non-covered” services. Therefore, you are
responsible for payment for the following services. These are the ranges of prices and are dependent on
the level or complexity of service provided.
 Telephone Consult $60.00 - $150.00
This will not be billed to your Insurance Company and
prepayment is required.
 Visit Cancellation or No Show Fee $35.00
(less than 24 hour notification)

__________ Patient’s Initials

_________ Patient’s Initials

 Psychological Testing $350.00
__________ Patient’s Initials
Some Insurance Companies will not pay for Psychological Testing.
If testing is ordered, we will verify eligibility for this testing.
If not eligible, prepayment for testing is required.
 Legal Issues (Estimate Available)

__________ Patient’s Initials

These services have been explained to me and I agree to be personally and fully responsible for
payment. I understand that prepayment of these services may be requested. I understand that the PPVI
staff will work with me to help me know when these are applicable.
Patient’s Signature _________________________________________________Date ______________
Guarantor’s Signature (if patient is minor) ______________________________Date ______________
Witness’s Signature ________________________________________________Date ______________
Revision August 2, 2017
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Author                          : Mary Anne Pawloski
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Create Date                     : 2017:08:02 16:29:03-05:00
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