Member Billing Acknowledgment. Required Form 2026

The document is a Member Billing Acknowledgment form for Medicare Advantage members, provided by American Specialty Health (ASH). It outlines the member's responsibility to self-pay for certain non-covered services not included in their Medicare Advantage plan. The form requires the member to acknowledge understanding of their financial obligations and to list specific services and charges. It emphasizes that this agreement is only valid for pre-approved non-covered services and cannot be used retroactively.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name in the designated field, followed by the name of the practitioner providing your care.
Specify the name of your health plan where indicated, ensuring accuracy for proper processing.
List each non-covered service you will self-pay for, including the date, procedure, and charge. Make sure to initial next to each charge.
If additional services need to be documented, attach more forms as necessary and repeat the listing process.
Review all entered information carefully before signing. Ensure you understand your financial responsibilities as outlined in the form.
Sign and date the form at the bottom, ensuring that all required fields are completed before submission.

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