MEET DR. SCELFO ABOUT AMENITIES MEDIA JOIN FAQ LOCATION CONTACT US MEMBERSHIP INVESTMENT RX REQUEST

ABN Cigna Form

(A) Notifier(s): James G. Scelfo, MD, PA DBA // Personalized Primary Care

(B) Patient Name: *

(C) Identification Number: *

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE:  If Cigna Health Plans (PPO, HMO and POS) doesn’t pay for (D) Yearly Membership Fee to Personalized Primary Care or the amenities listed on the first page of the PPC Membership Agreement below, you may have to pay.

Cigna does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Cigna may not pay for the (D) the yearly Membership Fee to Personalized Primary Care or the amenities listed on the first page of the PPC Membership Agreement below.

(D)

The yearly Membership Fee to Personalized Primary Care or the amenities listed on the first page of the PPC Membership Agreement

(E) Reason Cigna May Not Pay:

Is a non covered service not paid by any insurance company

(F) Estimated Cost:

Membership Fees
Individual Membership: $1,560.00
Couple Membership: $2,600.00
Child < 2: $520.00
Child > 2: $260.00

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.
  • Choose an option below about whether to receive the (D) listed above.

(G) OPTIONS: Check only one box. We cannot choose a box for you.

OPTION 1. I want the (D) listed above, but do not bill Cigna. You may ask to be paid now as I am responsible for payment. I cannot appeal if Cigna is not billed.

OPTION 2. I don’t want the (D) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Cigna would pay.

(H) Additional Information:

This notice gives our opinion, not an official Cigna decision. If you have other questions on this notice or Cigna billing, please call Cigna Health Plans.

I Agree to the Terms & Policies of this page.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0566. The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

Form CMS-R-131 (03/08)
Form Approved OMB No. 0938-0566