HEALTH CARE COVERAGE DISCLOSURE
Harrison T. Mu, M.D., F.A.C.S.
1a. In-Network Health Care Plan Coverage
Please note that the physician listed above, is participating or in-network providers under the following health care plans:
If you are a covered member of one of the above listed health care plans, the Practice will bill you only for the co-pay, coinsurance or deductible under your policy.
1b. Out-of-Network Health Care Plan Coverage
If you are a covered member of a health care plan that is not listed above, then please be advised that the physicians of this Practice are non-participating or “out-of-network” providers under your insurance plan. If you were referred to the physicians of this Practice by another physician or physician group that is a participating or in-network provider under your health plan, please be advised that such referral does not change the non-participating or out-of-network status of the physicians of this Practice. As such, some or all of the costs for the medical care provided by the physicians of this Practice may not be covered under your insurance policy or may be covered at a rate that is less than the amount the physicians of this Practice bill for such services. Please acknowledge that:
- You are aware the physicians of this Practice are non-participating (out-of-network) providers under your health care plan,
- If applicable, you consented to the referral to this Practice which is a non-participating (out-of-network) provider,
- You will be responsible to pay the full amount of the bill issued by the physicians of this Practice regardless of how much you are reimbursed by your health care plan for their charges.
2. Request for Estimate of Charges
Under New York State law, you are entitled to request an estimate of the amount you will be billed for any treatment you receive from the physicians of this Practice. If you elect to receive additional follow-up care from the physicians of this Practice and you wish to request an estimate of the costs of such care, the Practice will provide to you a written statement of the estimated amount of the charges for such care, absent any unforeseen medical circumstances that may arise during the course of treatment.