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27 11/2005
NOTICE OF POTENTIAL LIABILITY
BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA, INC.
HMO MEMBER/PATIENT
Patient Name _________________________________________________________________________
Address _____________________________________________________________________________
ID/Contract # _________________________________________________________________________
Group # _______________________________________ Date of Service ______/_______/_______
Based on the information available at this time, _______________________________ (Hospital) and Blue
Cross Blue Shield Healthcare Plan of Georgia, Inc. (BCBSHP) have determined that the following will not
be reimbursed by BCBSHP under the member’s Membership Agreement.
___________ Inpatient Admission for _______/______/______
___________ Additional Inpatient Treatment after ______/______/______
___________ Other Hospital 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 the Utilization Management Division of BCBSHP.
ACKNOWLEDGEMENTS: __________________________________________
Member/Patient Signature
__________________________________________
Member/Patient Name Printed
__________________________________________
Hospital Representative Signature
__________________________________________
Hospital Representative
__________________________________________
Date Time