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.