If the insurance plan does not pay for the medical services listed below, or we do not participate in your insurance plan, you will be required to pay out of pocket. The insurance plans do not pay for everything, even some care that you or your health care provider have good reason to think you need.
Reason the Insurance Plan May Not Pay: Non-covered service or Not in network provider
Estimated cost: $85-$250 depending on treatment. Cost may vary depending on the service/s
WHAT YOU NEED TO DO NOW:
Read this notice, so you can make an informed decision about your care. Please feel free to ask any questions that you may have after you finish reading this form. Choose the preferred option below.
This notice is not an official insurance plan decision. If you have other questions on this notice regarding insurance billing, please call your insurance company. Signing below means that you have received and understand this notice. You may also receive a copy.
I certify that this data is true, correct & accurate. I understand that payment of this claim will be from federal & state funds. Any false claims, documents, or concealment of material facts may be prosecuted under applicable laws. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.