Advance Beneficiary Notice (ABN)

Note:  You need to make a choice about receiving these health care items or services.

The purpose of this form is to help you make an informed choice about whether or not you want to receive online
ACNE E-VISIT ^® services, knowing that you will have to pay for them yourself.

Private insurance plans and Medicare do not pay for online healthcare or ACNE E-VISIT ^®  services.  The fact that Private insurance plans and Medicare do not pay for this unique service does not mean that you should not receive it.

Note:  Your health information will be kept confidential.  Any information that I collect about you on this online
ACNE E-VISIT ^® site will be kept confidential in our office and treated as any other medical record under the national guidelines set forth in the Health Insurance Portability and Accountability Act (HIPAA).

                                Important Message!!
Dr. Seraly is offering online Acne management for NEW!! (State of Pennsylvania) and established Patient's. 

PLEASE CHOOSE ONE OPTION.  CHECK ONE BOX

 Option 1.  Yes. I want to receive online ACNE E-VISIT ^®   services ($40/visit).

            I understand that my private insurance plan and Medicare will not pay for any online health care services or any health care service that is not directly delivered to the patient in a face-to-face manner.  I understand that I will be financially responsible for this service and agree to pay for these services independent of my health care provider. 

 Option 2.  No.  I have decided not to receive these items or services.

            I will not receive these items or services.  I understand that I will not be able to submit a claim to my private insurance plan or Medicare nor will I be able to appeal their opinion that private insurance plans and Medicare won’t pay for online 
ACNE E-VISIT ^® services.