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26 11/2005
NOTICE OF POTENTIAL LIABILITY
BLUE CROSS AND BLUE SHIELD OF GEORGIA, INC.
PPO MEMBER/PATIENT
Patient Name _________________________________________________________________________
Address _____________________________________________________________________________
ID/Contract # _________________________________________________________________________
Group # _______________________________________ Date of Service ______/_______/_______
Based on the information available at this time, _______________________________ (Hospital) and Blue
Cross and Blue Shield of Georgia (BCBSGa) have determined that the following will not be reimbursed
by BCBSGa under the member’s Membership Agreement.
___________ Inpatient Admission for _______/______/______
___________ Additional Inpatient Treatment after ______/______/______
___________ Other Hospital services ______/______/______
___________ Other Office services ________/________/__________
Expenses incurred for the above treatment(s) will be the responsibility of the member/patient.
Should the member or attending physician disagree with this decision, the member or the attending
physician should refer the matter to BCBSGa.
ACKNOWLEDGEMENTS: __________________________________________
Member/Patient Signature
__________________________________________
Member/Patient Name Printed
__________________________________________
Hospital Representative Signature
__________________________________________
Hospital Representative
__________________________________________
Date Time