Nexplanon Contraceptive Implant Financial Agreement

Nexplanon Contraceptive Implant Financial Agreement

I, ______________________________________, understand that the Nexplanon contraceptive implant

(patient name)

and insertion procedure may not be covered by my health insurer. Allegro Pediatrics will make every attempt to get this covered by your insurance; however, I agree to be financially responsible for any cost of the implant and insertion procedure in the event that it is not covered by my health insurance. The current cost of the implant and insertion procedure is $1,348. The implant must be removed at a future date and the current cost of that removal is $374. If you choose to have your implant removed and a new one inserted at the same time, that will cost $1,495.

If you would like to check coverage with your insurance ahead of time, you can give the following codes: ? Insertion of Nexplanon: CPT Codes 11981 and J7307, and ICD10 Code Z30.018 ? Removal of an old Nexplanon: CPT Code 11982 ? Both removal of an old Nexplanon and insertion of a new Nexplanon: CPT Codes 11983 and J7307, and ICD10 Code Z30.018

By my signature below, I agree to the above statement of financial liability:

______________________________________

Patient Name

_____________________

Patient Date of Birth

__________________________________________________

Signature of patient or parent/guardian if patient is under 18

______________________________________

Printed Name of Person Signing

_____________________

Date

______________________________

Relationship to Patient

E.FIN.F1.052323

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