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.
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
Patient name: Out-of-network provider(s)or facility name:
¥•Review your detailed estimate. See Page 4 for a cost estimate for each item or service you’ll get.
k 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.
k Questions about this notice and estimate?CaII \Enter contact information for a representative of the provider or facility to explain the documents and estimates to the individual, and answer any questions, as necessary.)
•Questions about our rights?Contact www.cms.gov/nosuprises or call 1-800-985-3059
Prior authorization or other care management limitations
Enter either(1) specific information about prior authorization or other care management limitations that are or may be required by the individual’s health plan or coverage, and the implications of those limitations for the individual’s ability to receive coverage for those items or services, or (2) include the following general statement:
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.]
[in the case where this notice is being provided for post-stabilization services by a nonparticipating provider within a participating emergency facility, include the language immediately below and enter a list of any participating providers at the facility that are able to furnish the items or services described in this notice)
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
Visit www.cms.gov/nosuprises or call 1-800-985-3059 for more information about your rights under federal law.
By signing, I give up my federal consumer protections and agree to pay more for out-of-network care.
With my signature, I am saying that I agree to get the items or services from (select all that apply):
0 \doctor’s or provider’s names elf consent is for multiple doctors or providers, provide a separate check box for each doctor or providers
Eastern Mane Eye Associates / Bangor Eye Surgery
With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:
I’m giving up some consumer billing protections under federal law.
I may get a bill for the full charges for these items and services, or have to pay out-of-network cost-sharing under my health plan.
I was given a written notice on Center date of notices explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.
I got the notice either on paper or electronically, consistent with my choice.
I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit.
I can end this agreement by notifying the provider or facility in writing before getting services.
IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.
Patient’s signature Print name of patient
Date and time of signature
Guardian/authorized representative’s signature
Print name of guardian/authorized representative Date and time of signature
Take a picture and/or keep a copy of this form.
It contains important information about your rights and protections.
More details about your estimate
Patient name: Out-of-network provider(s)or facility name:
The amount below is only an estimate; it isn’t an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
Enter the good faith estimated cost for the items and services that would be furnished by the listed provider or facility plus the cost of any items or services reasonably expected to be provided in conjunction with such items or services. Assume no coverage would be provided for any of the items and services.).
Populate the table below with each item and service, date of service, and estimated cost. Add additional rows if necessary. The total amount on page 2 must be equal to the total of each of the cost estimates included in the table.)
| Date | ofService code | Description | Estimated amount |
| Total estimate of what you may owe: | |||
