Get Non-covered Service Fee Acceptance Form - March Vision Care

Completing the Non-Covered Service Fee Acceptance Form is an essential step for individuals seeking services not covered by their insurance. This guide provides clear instructions for navigating the form online, ensuring users understand their responsibilities and options.

Follow the steps to complete the Non-Covered Service Fee Acceptance Form online.

1. Click ‘Get Form’ button to obtain the Non-Covered Service Fee Acceptance Form and open it in your editor.
2. In the first section, enter your name as the member requesting the service. Ensure accuracy in spelling and formatting to avoid issues later.
3. Specify the type of service requested and enter the name of the provider or doctor. This information is critical for processing your request.
4. Fill in the total cost of the service as described by your provider. This amount should align with what has been discussed and proposed.
5. Acknowledge your understanding of the payment responsibility. Indicate that you are aware that this service is not a covered benefit under your Medicaid/Medicare Program.
6. Sign the form in the designated area to confirm your acceptance of the terms and responsibility for the payment of the service.
7. Print your name clearly below your signature to ensure it is legible and matches your official documents.
8. Date the document to record when you completed the form. This is important for ensuring your acceptance is current.
9. Review all entered information for accuracy and completeness before proceeding to save, download, print, or share the form as required.

Complete your documents online today to ensure your services are processed without delay.