PREMIER WOMEN'S HEALTH

Contracted insurance: If we are contracted with your insurance company, we must follow our contract and their requirements. If you have a co-pay or deductible, you must pay that at the time of service. Contact your insurance company related to your benefits. Non-contracted insurance: Insurance is a contract between you and your insurance company. We are NOT a party to this contract, in most cases. If you have insurance that we are not contracted with, you will be considered an uninsured patient. Our billing office can provide you with an itemized statement after services are rendered that you may submit to your insurance for direct reimburse ment

I hereby assign all medical and surgical benefits to which I am entitled. I authorize and direct my insurance company/companies, including Medicare, private insurance, and any other health/medical plan to issue payment directly to Premier Women's Health.I understand I am responsible for any amount not covered by my insurance plan.

Balances are due upon receipt of a Patient Statement. Premier Women's Health accepts cash, check and creditcard (Visa, MasterCard, Discover, and American Express Checks returned for insufficient funds will be subject to a $35.00 service charge. There may be a $35.00 charge back services fee if credit card payments are "charged back" to my account. If I have an overpayment on my account, the amount will be applied to any outstanding balance on my account; any remaining credit will be refunded via a mailed check within 30 days of discovery if I do not have any upcoming appointments. Any balance that is overdue by 90 days may be placed with our outside collection agency, American Accounts and Advisors. If your balance is included in a bankruptcy, Premier Women's Health has the right to terminate your care as medically appropriate for future visits.

Premier Women's Health offers payment plans for balances over $50.00. To initiate a payment plan, I am required to set up a formal payment plan and make the first monthly payment. If at any time I fail to make the agreed upon payment, my account may be placed with an outside collection agency, American Accounts and Advisors.

It is my responsibility to check my insurance plan concerning coverage for services provided by Premier Women's Health in addition to verifying network status (in-network/out-of-network

All co-payments are due at the time of service. Premier Women's Health will not routinely waive or discount any co-payments, co-insurance or deductibles in accordance with state and federal law or applicable participating payer agreements. Out-of- network plans will be subject to out-of-network benefits, deductible, co-insurance and co-pay amounts.

It is my responsibility to obtain any referrals required by my insurance plan to be seen at Premier Women's Health. Referrals should be obtained prior to scheduling my appointment. If I do not obtain the proper referral, any claims that are denied by my insu rance plan are my responsibility.

If I do not have insurance at the time of service, I will be required to make a payment toward my visit. Non-obstetrical patients are required to pay in full prior to the visit or at the time of the visit. Obstetrical patients are expected to pay $475.00 at every visit for on-going prenatal care. If I do not make a payment, I may be asked to reschedule my appointment. Uninsured patients with accounts in good standing will receive a 20% discount.

Unless you instruct us to the contrary, some lab work may be sent to one of our outside labs (M Health Fairview Lab, Natera, Sequenom, and Unity lab If your insurance requires you to use another lab, please be sure to inform the nurse at the beginning of your appointment. It is important for you to know which laboratories are in-network with your insurance carrier. We send a large majority of lab specimens to an outside lab and therefore, we do not charge for the actual test; the lab will bill you separately. Contact the Premier Women's Health Business Office at 651-461-8866 with any questions related to this Financial Notification.