ASC Revenue Cycle E-Tool: Confirmation of Notification to Treat Out-of-Network Member as In-Network Form

Use this sample form when planning to treat a patient with third-party payer coverage at your non-contracted, out-of-network facility. Contact the payer and complete this form if it agrees to pay your ASC at in-network rates. Ensure that you have all the necessary information listed below if the payer does not reimburse you correctly. Adapt this form for use in your surgery center.

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