Under Sec. 111 in the H.R. 133, the Consolidated Appropriation Act, health plans are required to send patients an Advance Explanation of Benefits (AEOB) after receiving a good faith estimate notification from a provider or facility that an individual is scheduled to receive an item or service. In addition, 2009 Wisconsin Act 146 requires hospitals, insurance plans, and health care providers to disclose information about the cost and quality of health care services. Complete the request form to obtain an estimate of out-of-pocket expenses for the member.
Use this personal health record form to record and maintain a history of your health information. Keep your personal health summary handy, and bring it to your health care office visits so you can talk with your health care provider about preventive care.