Please provide a brief description of the service you are providing and why the service may reject and not be paid ALLERGEN EXTRACT - PER BCBSM RULES - PATIENT RESPONSIBILITY IS DETERMINED BY THE PATIENT NOTIFYNG PROVIDER OR BY CANCELLING APPOINTMENTS THAT THEY ARE NOT FOLLOWING THROUGH WITH THE TREATMENT OR TREATMENT IS NEVER STARTED
Provider Name(s): Allergy Associates of Western Michigan 3185 Macatawa Dr SW Suite B Grandville, Michigan 49418-1274
Erica Palmisano, MD 1629367081
Thomas P. Miller, MD 18471210895
Provider Instructions: Please fill in the fields below and have the Blue Cross member/patient sign and date the "Member's acknowlegement and agreement to pay for services" section.
MEMBER'S acknowledgement and agreement to pay for services
My health care provider has notified me that the services listed above may not be payable by Blue Cross Blue Shield of Michigan in the event treatment is not continued or treatment is not started. I understand that payment for these services will be my responsibility. I agree to be responsible for payment
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