Turkle & Associates Surprise Billing Protection Form
Surprise Billing Protection Form
The purpose of this document is to let you know about your protections from unexpected medical bills. It also asks whether you would like to give up those protections and pay more for out-of-network care.
You’re getting this notice because this provider or facility isn’t in your health plan’s network. This means the provider or facility doesn’t have an agreement with your plan.
Getting care from this provider or facility could cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills:
- When you get emergency care from out-of-network providers and facilities, or
- When an out-of-network provider treats you at an in-network hospital or ambulatory surgical center without your knowledge or consent.
Ask your health care provider or patient advocate if you need help knowing if these protections apply to you.
If you sign this form, you may pay more because:
- You are giving up certain legal protections against balance billing.
- You may owe the full costs billed for items and services
- Your health plan might not count any of the amount you pay towards your deductible and out- of-pocket Contact your health plan for more information.
You shouldn’t sign this form if you didn’t have a choice of providers when receiving care. For example, if a doctor was assigned to you with no opportunity to make a change.
Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, your health plan might work out an agreement with this provider or facility, or another one.
See the next page for your out-of-network cost estimate.
By signing this consent form, I give up my federal and state consumer protections and agree to pay more for out-of-network care.
With my signature, I agree to receive the items or services from (select all that apply):
- Janet Turkle
- Turkle and Associates
With my signature, I acknowledge that I am consenting of my own free will and am not being coerced or pressured. I also understand that:
- I am giving up some consumer billing protections under federal and state
- I may get a bill for the full charges for these items and services or have to pay out-of-network cost-sharing under my health
- I was given a written notice beginning 1/3/2022 explaining that my provider or facility isn’t in my health plan’s network, the estimated cost of services, and what I may owe if I agree to be treated by this provider or facility.
- I received the notice either on paper or electronically, consistent with my
- I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket
- I can end this agreement by notifying the provider or facility in writing before getting
IMPORTANT: You don’t have to sign this form. But if you don’t sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.
Or Patient’s signature Guardian/authorized representative’s signature
Print name of patient Print name of guardian/authorized representative
Date and time of signature Date and time of signature
Take a picture and/or keep a copy of this form.
It contains important information about your rights and protections.
Details about your estimate
Patient name: Out-of-network provider(s) or facility name: Dr. Janet Turkle, Turkle & Associates
The amount below is only an estimate; it isn’t an offer or contract for services that binds you to be treated by this provider. This estimate shows the full estimated costs of the items or services listed. It doesn’t include any information about what your health plan may cover. This means that the final cost of services may be different than this estimate.
The estimate of our intended charge for treatments from Turkle & Associates set forth in this statement is provided in good faith and is our best estimate of the amount we will charge. If our actual charge for treatments from Turkle & Associates exceeds our estimate by the greater of: (i) one hundred dollars ($100); or (ii) five percent (5%); we will explain to you why the charge exceeds the estimate
Contact your health plan to find out how much, if any, your plan will pay and how much you may have to pay.
|Service code||Description||Estimated amount
to be billed
|Total estimate of what you may owe:|