631-231-4949
601 Suffolk Avenue
Brentwood, New York 11717

NY Medical Bill Disclosure

Notice Of Right To Request Information About The Amount Or The Estimated Amount That Long Island Ambulatory Surgery Center Will Bill You If Long Island Ambulatory Surgery Center Is Not A Participating Provider In Your Health Insurance Plan

Effective Date: 8/30/2015

In accordance with New York Law, you have the right to receive this notice prior to the provision of non-emergency services by Long Island Ambulatory Surgery Center.

  1. If Long Island Ambulatory Surgery Center is not a participating provider in your health insurance plan, then information regarding the amount or estimated amount that Long Island Ambulatory Surgery Center will bill you for medical services is available to you upon request (so long as the medical service is not an emergency service).
  2. Upon receipt of such a request from you, Long Island Ambulatory Surgery Center must disclose to you in writing the amount or estimated amount that it will bill you for the medical services provided or anticipated to be provided to you, absent unforeseen medical circumstances that may arise when the services are provided.

THIS ONLY APPLIES IF LONG ISLAND AMBULATORY SURGERY CENTER IS NOT A PARTICIPATING PROVIDER IN YOUR HEALTH INSURANCE PLAN

Patient Acknowledgement of Receipt of Notice of Right to Request Information from Long Island Ambulatory Surgery Center about the Amount or Estimated Amount that Long Island Ambulatory Surgery Center will bill you directly for Medical Services.


This Notice provides information to you about your right to request from Long Island Ambulatory Surgery Center information about the amount or estimated amount that Long Island Ambulatory Surgery Center will bill you directly for Medical Services if Long Island Ambulatory Surgery Center is not a participating provider in your Health Insurance Plan.

By signing this form, you acknowledge that you have received this Notice of Your Right to Request Information from Long Island Ambulatory Surgery Center about the Amount or Estimated Amount that Long Island Ambulatory Surgery Center will bill you directly for Medical Services.

_____________________________________

Name of Patient or Patient Representative


_____________________________________

Signature of Patient or Patient Representative

Date: _________________________________

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