PATIENT ACKNOWLEDGMENT FOR NON-COVERED SERVICES

Medicare will only pay for services that it determines to be reasonable and necessary under section 1862 (a) (1) of the Medicare Law. If Medicare determines that a particular service, although it would otherwise be covered, is not reasonable and necessary under the Medicare Program standards, Medicare will deny payment for that service. By signing the Patient/ Responsible Party Signature on the front of this requisition, you are confirming your agreement to assume financial responsibility for the payment of these tests.