Healthcare Rate Pages

HEALTHCARE RATE PAGES

Provider Name:   Billing Contact:

Rate Schedule and Fee Definitions

Effective Date of These Rates: . These rates constitute the standard charges for listed services before application of insurance negotiated discounts, contractual adjustments, or patient-specific discounts. Provider reserves the right to change listed rates prospectively upon reasonable notice to patients.

Service Fee Schedule (representative items)

Definitions: "Standard Charge" means the full undiscounted charge typically billed by the provider for the service listed. "Negotiated/Insured Rate" is the contracted rate between provider and payer before patient cost‑sharing. "Cash Price" is the amount a self‑pay patient would be charged at time of service when paying in full without taking assignment of insurance proceeds.

Patient Information

Date of Birth:   Gender:

Phone:   Email:

Insurance Information

Policy Number:   Group Number:   Subscriber Name:

Payment Terms, Estimates & Billing Policies

Patient Responsibility: Unless otherwise specified by a separate agreement, the patient is responsible for applicable deductibles, copayments, coinsurance and non‑covered services. Provider will bill the insurer as a courtesy when assignment of benefits is provided; payment of patient responsibility is due according to the provider's regular billing terms.

Estimates: The cash price or good faith estimate provided herein is an approximation of the expected charge for the listed service. Actual charges may vary depending on clinical circumstances. Requests for a written estimate can be submitted in advance; final billed amounts will reflect services actually rendered.

Collections and Delinquency: Outstanding balances unpaid after notice and the stated payment period may be referred to collection and may include collection costs and interest as permitted by law. Patients have the right to request an itemized bill and to appeal disputed charges under the provider's billing dispute procedures.

Financial Acknowledgment & Assignment of Benefits

By signing below the patient (or authorized representative) acknowledges receipt of this Healthcare Rate Pages document, understands the differences between standard charge, negotiated/insured rate and cash price, and agrees to be responsible for charges as set forth above. Patient further authorizes the provider to release medical and billing information necessary to process claims and agrees to assignment of benefits to the provider unless otherwise indicated.

I authorize assignment of insurance benefits to the provider.

I acknowledge financial responsibility for services not covered or paid by my insurer.

HIPAA Acknowledgment

I acknowledge that I have received or been offered the provider's Notice of Privacy Practices that explains how my medical information may be used and disclosed, and how I can access this information. I understand that the provider may contact me regarding billing, appointment reminders and healthcare treatment in accordance with the privacy practices.

I acknowledge receipt of the Notice of Privacy Practices.

Dispute and Appeal Procedures

Any dispute concerning interpretation of these rates or billed charges should be submitted in writing to the provider's billing department. Provider will review disputes and communicate findings in writing. Disputes that cannot be resolved through informal review may be subject to applicable external appeals or dispute resolution mechanisms where available by law or contract.

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