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 are not required to sign this form and should not sign it if you didn’t have a choice of healthcare 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 would like assistance with this document,
ask your provider.
Take a picture and/or keep a copy of this form for your records.
This notice applies if this provider or facility is not in your health plan’s network. This means theprovider or facility does not 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 are 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 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 is not one, your health plan might work out an agreement with this provider or facility, or another one.
Estimate of what you will pay
Out-of-network provider(s)or facility name: Raleigh Wellness Behavioral Health
Total cost estimate of what you may be asked to pay: New Patient Visit $300, Established 20-30 min appointment $150 , Established 40 min appointment $175
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 the practice
Questions about your rights? Visit https:/
www.ncleg.gov/EnactedLegislation/Statutes/HTML/BySection/Chapter_58/GS_58-3- 200.html for more information about your rights under N.C. state 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 all providers at Raleigh Wellness Behavioral Health
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 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.