A. Notifier: Align Clinic, LLC, 700 South Claremont St. Ste 105, San Mateo, CA 94402, (650) 375-2231

WCR Brace Advance Beneficiary Notice of Noncoverage (ABN)

The minimum reimbursement for the WCR brace is $5,300 total. If your insurance does not cover up to this amount, you are responsible for the difference.

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.

I want the items or services listed above. You may ask to be paid now, but I also want my insurance company billed for an official decision on payment. I understand that if my insurance company doesn’t pay or does not cover at least $5,300, I am responsible for payment up to $5,300 (WCR price) but I can appeal to my insurance company. If my insurance company does pay, Align Clinic will refund any remaining amount I paid after the $5,300 balance has been satisfied.

This notice gives our opinion, not an official insurance company decision. Signing below means that you have received and understand this notice. You may also receive a copy upon request.

Device Type :     Wood Cheneau Rigo Brace

Your email:

Date:

Printed name :

Relationship to patient :

Sign here ( use the mouse or your finger on mobiles or tablets ) :

This form must be sent to:
---San Mateo - CA (Jolene Freeman)Green Bay - WI (Lynn Chervenka or Marsha Holtzheimer)The Woodlands - TX (Norma Prieto)Lauderdale - FL (Lynn Chervenka or Marsha Holtzheimer)Boulder - CO (Stephanie Romero)

Please check that all information is completed and try to submit the form until you receive a successfully sent message, thanks.