Medical Assistance Advance Recipient Notice of Non-Covered Service/ Item Form
The Advance Recipient Notice of Non-Covered Service/Item form is used to protect A Chance To Grow and you as a Medical Assistance Recipient from acquiring outstanding bills. This form gives A Chance To Grow the right to bill Medical Assistance for services if they do not meet program requirements for the state of Minnesota.

​​Please download the Advance Recipient Notice of Non-Covered Service/Item form, read, sign and save.  You can print it and fax it us a signed copy at (612) 706-5555 or submit by uploading your completed document by using the upload form. Please print completed documents for your personal records.

Data Privacy
We invite you to visit our Privacy Practices page to review our policies regarding the security of your information. This page describes how medical information about you may be used and disclosed and how you can get access to this information.
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If you have questions or need more information, please contact us by calling (612) 789-1236 or email rehabclinic@actg.org.
The Advance Recipient Notice of Non-Covered Service/Item form lists several reasons why services provided may not covered. The following are reasons that pertain to A Chance To Grow:
  1. Insurance Lapse/Termination 
    A Chance To Grow will only utilize this form if the client becomes inactive from his/her insurance. If you have Medical Assistance or a Pre-Paid Medical Assistance Program (PMAP) through another HMO and you are not reinstated on Medical Assistance, we will then bill you for services rendered after the date of the lapse of coverate. ACTG checks your insurance on the 1st of every month in order to catch any discrepancies that we find. If your insurance is found to be inactive, we will notify you and discharge services until coverage is reinstated.

  2. Non-Covered Service/Benefit 
    This form also states that if you have Medical Assistance and any of our services are excluded from your level of coverage that you will be responsible for those services, such as a co-pay. We will always check your insurance benefits prior to starting services with A Chance To Grow and inform you of any exclusions. 

  3. Individual Education Plan (IEP) 
    If you have an IEP that is federally funded not state funded like Medical Assistance and are being seen for Occupational or Speech Therapy we are required to attempt to obtain a copy of the current IEP. This is used to make sure that any services we provide compliment your IEP and do not duplicate services. If we do not have a copy of the IEP and it is determined that we are violation of duplicating services with an IEP, you are responsible for the payment. 

  4. Physician Order Not Signed/Obtained 
    If your primary care physician refuses to sign an evaluation order or a treatment plan, you will be responsible for the services provided. It is a reuirement that Occupational Therapy, Speech Therapy, and Audiology services have a signed order for evaluation, and each treatment plan must be signed in order for us to treat a client. If a doctor refuses signature we will inform you prior to continuation services.

This information is directly provided from Minnesota Health Care Programs. Acknowledgement requires signature on this document for insurance-based services provided at A Chance To Grow.