Commercial Insurance Waiver / Notice of Non-Coverage Template

Commercial Insurance Waiver / Notice of Non-Coverage Template

Here is a comprehensive template for a Commercial Insurance Waiver / Notice of Non-Coverage.

You can copy and paste this into a Word document or your Electronic Health Record (EHR) system.

[Insert Your Practice/Laboratory Name Here]
[Insert Address]
[Insert Phone Number]

ADVANCE NOTICE OF NON-COVERAGE (Commercial Insurance)

Patient Name: ___________________________________________________
Date of Birth: ________________________
Insurance Carrier: ________________________________________________

NOTE TO PATIENT:
Your healthcare provider has recommended the services or tests listed below. However, based on our understanding of your health insurance plan, we believe your insurance carrier is likely to deny payment for these specific services.

Insurance companies determine coverage based on "Medical Necessity" criteria, frequency limits (how often a test is done), and specific plan exclusions. If your insurance denies these claims, you will be personally responsible for the cost.

We want to ensure you are fully informed of the estimated costs before you decide to proceed.

            Service / Test Name              CPT Code (Optional)      Reason for Expected Denial                   Estimated Cost
(Example: Vitamin D Screen)(82306)[ ] Diagnosis not covered[ ] Frequency limit exceeded[ ] Experimental/Investigational$55.00
[ ] Diagnosis not covered[ ] Frequency limit exceeded[ ] Experimental/Investigational
[ ] Diagnosis not covered[ ] Frequency limit exceeded[ ] Experimental/Investigational

Total Estimated Cost: $__________________

OPTIONS (Check One):

[ ] Option 1. I want the services listed above.
I understand that my insurance is likely to deny payment for these services. I agree to be personally and fully responsible for payment. I understand that I will be billed for these services if my insurance company denies the claim.

[ ] Option 2. I DO NOT want the services listed above.
I understand that my doctor has recommended these services for my medical care, but I am choosing to decline them at this time due to the potential cost. I accept any risks associated with not receiving these tests/services.

Patient / Guardian Signature: ___________________________________________________
Date: ________________________

Witness (Staff) Signature: ___________________________________________________
Date: ________________________

Instructions for Staff (Internal Use Only):

  1. Do not use this form for Medicare patients. Use the official CMS-R-131 (ABN) form for Medicare.
  2. Be Specific: You must fill in the "Service Name" and "Estimated Cost." A blank or vague waiver is not legally binding.
  3. Timing: This form must be signed BEFORE the specimen is collected or the service is rendered.
  4. Scanning: Scan this signed document immediately into the patient's documents and tag it as "Billing/Consents."


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