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Tackle HPV Vaccine Payment Woes With A Solid Financial Responsibility Form

Published on Mon Oct 03, 2011

The more specific your form is, the better your payment odds.

If you aren't having your pediatric patients sign an ABN form noting that they'll be responsible for male Gardasil® vaccine payment, you could be leaving money on the table. Avoid lost reimbursement with a form like this one, which you can tailor to your practice's specific needs:

Smith Pediatrics

Address

Phone Number/Fax Number

Patient Waiver Statement and Certification

I understand that the human papilloma virus (HPV) vaccine that Smith Pediatrics is about to administer to my son is usually considered a non-covered benefit for male patients under my insurance plan.

I further understand that I am responsible for the total balance due related to the vaccine administration, product, and other services related to the HPV vaccination as charged, and will pay in full at the time of delivery.

Should there be any reimbursement from my insurance company, it is mine to keep but such "coverage" does not subject Smith Pediatrics to accept my insurance company's fee schedule.

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