Get Patient Responsibility Form

The Patient Responsibility Form is an essential document for acknowledging the financial responsibilities associated with your healthcare. This guide will provide you with step-by-step instructions to assist you in accurately completing the form online.

Follow the steps to successfully complete the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Review the form's introductory instructions, which explain the purpose of the document and the importance of acknowledging your financial responsibilities for non-covered services.
3. In the 'Procedure Code' section, input the code associated with the non-covered service you have been informed about.
4. In the 'Description of Service' field, provide a brief overview of the service for which you acknowledge financial responsibility.
5. In the 'Charges' section, state the cost associated with the services. Ensure that this reflects the amount that you are expected to pay.
6. Enter the 'Provider Name' to confirm the healthcare provider offering the specified services.
7. Print your name in the 'Member Name' field, ensuring clarity in identifying the individual responsible for this form.
8. Provide your US Family Health Plan ID number in the designated field to link your acknowledgment to your membership.
9. Sign your name in the 'Member's Signature' area. If you are signing on behalf of a minor, please indicate this accordingly.
10. Date the acknowledgment to confirm when the responsibility was accepted.
11. Once you have completed all fields, review the form for accuracy. Then, save any changes, download, print, or share the completed form as necessary.

Complete the Patient Responsibility Form online to ensure you acknowledge your financial responsibilities properly.