Horizon Blue Cross / Blue Shield Insurance Financial Responsibility



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Horizon Blue Cross / Blue Shield Insurance Financial Responsibility

As a courtesy to you, we have submitted your bill to Blue Cross / Blue Shield of NJ on your behalf.

In many cases the insurance carrier will mail a check directly to your home address. This payment is for services rendered by Atlantic Pediatric Orthopedics and needs to be forwarded to our address in order to apply it to your accounts. We request that you endorse the back of the check and under your signature, please write “Pay to the order of Atlantic Pediatric Orthopedics” and forward it to our office within 5 days of receipt. We also ask that you send a copy of the Explanation of Benefits with the check to the address provided below:

Atlantic Pediatric Orthopedics, P.A

P.O. Box 283

Rumson, NJ 07760-0283

I understand and acknowledge receipt of this letter.

Signature:___________________________________________Date:____________________



Printed Name:________________________________________________________________

Relationship to patient:________________________________________________________


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