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- Click ‘Get Form’ to open it in the editor.
- Begin by reviewing the items or services listed under 'Items or Services'. This section outlines what your insurance may not cover, such as consultations and specific treatments.
- Carefully read the instructions provided in the notice. It is crucial to understand why your insurance might not pay for these services before making a decision.
- Choose one of the options provided at the bottom of the form. Check either 'Option 1' if you wish to receive the services, or 'Option 2' if you decide against them.
- Fill in your name and date in the designated fields. Ensure that all information is accurate.
- Sign the form where indicated, confirming your choice regarding the services.
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