Each of these areas except the “Copy Provided to Patient” (at the bottom) are highlighted to help our staff quickly review the areas of the form that must be fully completed, in order for the entire form to be valid.
The only areas to be filled out in advance of providing the form to the patient are the patient’s name and account number. Filling in any other areas of this ABN is unacceptable and invalidates the form. (You can point out to the patient that he or she must check the box (OPTION 1) indicating that they desire the service covered by the ABN; you should NOT check the box for the patient).
A key part of your duties at The Eye Institute, when checking patients out, is to carefully look through each patient’s out guide for forms or other documents that may require you to take some action.
If an ABN is present, you must review the form and determine if all of the required areas are completed.
If the patient's identification is not clearly filled out, you must be sure to add information here (name and/or account number) in order that the patient’s identity be clearly established.
When you have verified that all required areas of this form have been appropriately completed, you are to note the portion of the form indicating that the patient has received a copy of it, and provide the patient a copy of this form.
NOTE: You must look at the OPTIONS box carefully. If none have been filled out, review this with the patient and politely ask the patient to check OPTION 1. If the patient refuses to check this box or if any box other than # 1 has been checked, you are to immediately bring this to the attention of an onsite supervisor or manager to address.
This policy must be strictly adhered to without exception.