Healthcare No Surprise Bill

HEALTHCARE NO SURPRISE BILL NOTICE

Patient Name:    Date of Birth:

Patient Contact & Identification

Provider / Facility Information

Date(s) of Service:    Place of Service:

Insurance Information

Billing Summary — Itemized Charges

List each billed item or service. Include provider, code or description, and charge amount.

Total Amount Billed: $    Insurance Payments / Adjustments: $    Patient Responsibility (Balance): $

Notice of Rights and Dispute Procedures

This notice explains your rights concerning balance billing and disputed amounts. You may not be required to pay amounts in excess of your insurer's allowed amount where the provider is in-network, except where you knowingly and voluntarily consented to receive services from an out-of-network provider after being informed of likely charges. If you believe this bill is a surprise or you were balance-billed in error, you have the right to request an itemized explanation, submit a written dispute, and pursue independent dispute resolution where applicable.

To initiate a dispute, provide a written description of the basis for dispute and any supporting documentation. The provider will acknowledge receipt and respond in writing. You should retain all supporting records. Requests to dispute must be submitted no later than or within the timeframe specified by the payer or applicable policy.

Provider Certification

I certify that the foregoing information is accurate to the best of my knowledge, that the charges reflect services actually rendered, and that the billing entity has provided the patient with any required disclosures regarding network status and potential balance billing prior to the date of service when applicable.

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