Out of Network Acknowledgement

I have been informed that the practice/provider  is out-of network with my health insurance plan and further:

• My potential financial responsibility may exceed my copayment, deductible or coinsurance with my health insurance plan

• I may be responsible for any excess amount above the allowed amount the health insurance plan pays or reimburses the provider for healthcare services I received; and

• I should contact my health insurance plan to identify the specific potential costs for which I am/may be responsible.

• I should contact my health insurance plan and ensure needed referral authorizations are obtained and provided to provider/practices before services are rendered as outlined by my insurance for utilizing out of network benefits.

• Depending on the complexity of today’s service,  CPT Codes for the visit will be in the range of 99202-99205 if you are a new patient to HMH and 99211-99215 if you are an established patient.  The maximum charge if you are self pay (not covered by insurance) is $355.00

I acknowledge that I am knowingly and voluntarily accepting responsibility for any out-of network financial responsibility associated with healthcare service that I receive.