Healthcare Menu of Services

HEALTHCARE MENU OF SERVICES

Provider Information

Patient Information

Patient Name:

Date of Birth:    Gender:

Menu Effective Date

This Menu of Services is effective as of and provides typical descriptions and estimated charges for commonly furnished services. Estimates are not a guarantee of payment from any payer.

Itemized Services and Estimated Charges

The following table lists commonly provided services, a brief description, the typical billing code or internal identifier, and a range of estimated charges. Actual patient financial responsibility will vary based on insurance, contractual adjustments, deductibles, coinsurance, and benefit limitations.

Payment, Insurance, and Billing Policies

Provider will bill third-party payers when appropriate. Estimated charges listed herein do not include contractual adjustments, insurer reductions, or patient cost-sharing. Patient is ultimately responsible for all charges not paid by the insurer, including deductible, copayment, coinsurance, non-covered services, and charges resulting from failure to obtain required preauthorization.

Provider will attempt to obtain prior authorization or predetermination when clinically appropriate. Authorization is not a guarantee of payment. Patient must verify coverage and benefits with their insurer when necessary.

If a service is denied by the insurer, patient agrees to cooperate with Provider in pursuing appeals or alternate coverage and to satisfy payment obligations if insurer ultimately denies payment.

Estimates, Validity, and Patient Rights

Estimates provided on this Menu are based on typical service patterns and average charges. They are non-binding and provided for informational purposes. Actual charges may vary depending on clinical findings, supplies, implants, ancillary services, and service complexity.

Patient has the right to request an individualized, written estimate for a specific service or course of treatment. Written estimates will include a statement of expected patient financial responsibility based on information available at the time of the estimate.

Notice of Non-Covered and Ancillary Services

Certain services, supplies, or ancillary items may be billed separately from the primary procedure and may not be covered by all payers. Examples include durable medical equipment, laboratory tests sent to external laboratories, clinician professional fees separate from facility fees, and implantable devices. Patients are responsible for costs of non-covered items.

HIPAA / Privacy Notice Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices describing how protected health information may be used and disclosed and the patient's rights with respect to that information. Receipt of the Notice does not authorize any disclosure beyond that described in the Notice.

Acknowledgment and Financial Agreement

By signing below, the patient or authorized representative acknowledges that they have received and reviewed this Menu of Services, understands that cost estimates are approximate, and agrees to the Provider's billing and payment policies as described above. The patient authorizes Provider to bill the listed insurer and any other applicable payers and to release information necessary to process claims.

If signing as a personal representative, guardian, or guarantor, I certify that I am authorized to sign on behalf of the patient and that the information provided is true and correct to the best of my knowledge.

Sign Now