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.
I agree to pay Provider for those services and products determined for the reason(s) specified below not to be covered under my health care benefit plan:
I understand that the Provider and/or I may appeal any determination that a service or product is not medically necessary or noncovered by filing a grievance or appeal pursuant to the grievance and appeals procedures described in my healthcare benefit plan or Evidence of Coverage.
I also understand that I am financially responsible for the difference between the covered expense (“Allowed Amount”) for any covered services and products and the Total Cost listed below (“Member’s (Patient’s) Responsibility”), even though these amounts may not be shown on my Explanation of Benefits as my responsibility. If the Total Cost of the service and/or product is not covered under my health care benefit plan, I understand that I am financially responsible for the Total Cost. Or I may, in some situations, have the option to choose an upgraded version of a product. If the Provider’s usual and customary charge for the upgraded product is higher than the reimbursement rate for the standard product as covered by my health care benefit plan, I understand and agree that I am financially responsible for the difference between my health care benefit plan’s reimbursement rate for the standard model and the Provider’s usual and customary charges for the deluxe or upgraded model. This difference, if any, is indicated in the “Member’s (Patient’s) Responsibility” on the item receipt issued at checkout.
Date of Service
Amount of Service / Product / Upgrade Member’s (Patient’s) Responsibility*
I acknowledge that SunMED Medical/A Personal Touch Boutiques has reviewed this Responsibility Agreement with me, and I have had an opportunity to ask questions. I also acknowledge that SunMED Medical/A Personal Touch Boutiques offered me the standard piece of equipment, which was the least costly alternative, and SunMED Medical/A Personal Touch Boutiques explained to me that my health care benefit plan would only pay, at the most, the allowed amount under my contracted plan, subject to its usual eligibility requirements.
*In addition to being financially responsible for this amount, I understand that I will be billed and held financially responsible for any applicable copayment, deductible and/or coinsurance as required by my health care benefit plan or Evidence of Coverage.
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