New type of health plan unleashes the power of cash……………..
MEDICAL SERVICES CASH PAY PROGRAM ELECTION FORM
STEP 1 – Provider Completes Request – The provider completes this form with the member’s information and the services to be rendered. The patient then submits it to the Health Plan.
STEP 2 – Health Plan Determines Cash Pay Amount – The Health Plan reviews the request and enters the approved Cash Pay Allowed Amount for each service.
STEP 3 – Provider Accepts or Rejects Offer – The provider reviews the Health Plan’s Cash Pay Allowed Amount and either accepts or rejects the offer before services are rendered.
SERVICES TO BE RENDERED
PROVIDER CERTIFICATION
I certify that the information contained on this form is true and accurate. I further certify that the services listed above are medically appropriate for the identified member.
If I accept the Health Plan’s Cash Pay Allowed Amount, I agree to accept that amount as payment in full for the approved services listed on this form. I understand that no additional payment will be sought from the member.
Provider Signature: __________________________________________________________
Printed Name_____________________________________________ Date: ____ / ____ / _______
HEALTH PLAN USE ONLY
Request Status: ☐ Approved ☐ Modified ☐ Denied
ReviewedBy: Review Date: ____ / ____ / _______
