The attached form is for physicians to give patients who are receiving services that you have a reasonable belief will be a noncovered service by their private insurance or health plan.
Note: if the patient chooses to decline the procedure under Option 3 on the Notice of Noncoverage Under Private Health Plan, the physician should document in the record that he or she has discussed with the patient the risks and benefits of undergoing and not undergoing the procedure in question, and that the patient has opted to decline the procedure with full knowledge and information as to the risks.
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