For non-Medicare patients, use this form as a springboard to creating your own custom document. If you aren't having your non-Medicare patients sign a form saying they're responsible for paying on services or procedures that you know their insurance won't cover, you're leaving money on the table. Avoid lost reimbursement with a form like this one from Barbara J. Cobuzzi, MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.