Surprise Billing Protection Form
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
IMPORTANT: You aren’t required to sign this form and shouldn’t sign itif you didn’t have a choice of health care provider when you received care. You can choose to get care from a provider or facility in your health plan’s network, which may cost you less. If you’d like assistance with this document, ask your provider or a patient advocate. Take a picture and/or keep a copy of this form for your records.
You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.
Getting care from this provider or facility could cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills:
- When you get emergency care from out-of-network providers and facilities, or
- When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.
If you sign this form, you may pay more because:
- You are giving up your protections under the law.
- You may owe the full costs billed for items and services received.
- Your health plan might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.
You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change. Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one. See the next page for your cost estimate.
Estimate of what you could pay:
Review your detailed estimate. See Page 4 for a cost estimate for each item or service you’ll get.
- Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what’s covered under your plan and your provider options.
- Questions about this notice and estimate?Call Contact our office at (866) 220-8371
- Questions about your rights? Contact our office at (866) 220-8371 or email@example.com. You may also go to www.cms.gov/nosurprises for more information about this law and your rights.
Prior authorization or other care management limitations
Except in an emergency, your health plan may require prior authorization (or other limitations) for certain items and services. This means you may need your plan’s approval that it will cover an item or service before you get them. If prior authorization is required, ask your health plan about what information is necessary to get coverage.
Understanding your options
You can also get the items or services described in this notice from these providers who are in-network with your health plan:
More information about your rights and protections
You may also go to www.cms.gov/nosurprises for more information about this law and your rights.