LR MEDICAL PLLC

2279 Coney Island Ave Suite#2A Brooklyn, NY 11223 T: 718-998-9890 F: 718-998-9891

Information for Out –of-Network Services: Health Care Plan Information and Patient Financial Responsibility

Thank you for choosing LR Medical, PLLC (the “Practice”) as your healthcare provider. We are honored by your choice and are committed to provide you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of out-of-network (“OON”) services and your patient responsibilities for OON services.

Insurance Participation:

Attached to this form is a list which sets forth the health care plans and/or products in which the Practice and its physicians and physician’s assistants participate. The list also includes the hospital affiliations of our physicians. You may also access this information on our website at painfreenyc.com

Out –of –Network Services:

Prior to your first office visit, we will contact your health care plan to verify your OON benefit coverage.

As a courtesy, we will submit all claims to health care plans for the services we provide. If the Practice and physician doesn’t participate in your health care plan or product, you may incur higher out-of-network expenses for OON services than you would incur for services provided by in-network provider.

If we are OON, you may request information about the estimate amount that the Practice will bill for the OON services (absent unforeseen medical circumstances). To request information about these estimated costs, please contact our Billing Department at 718-998-9890/or fax your inquiries to 718-998-9891. You may also contact our Billing Department with questions about our financial policies.

Patient Responsibility:

You are required to provide us with the most correct and updated information about your health care plan coverage. You are responsible for the payment of your deductible and/or co-insurance and any other amount that your health care plan may not cover.

Payment for OON services is due at the time of the service. For your convenience, we accept cash, checks and most major credit cards at our office. Any and all amounts for which you are responsible may be subject to collection efforts consistent with applicable law, rules and regulations. You may also be responsible for additional amounts, including, but not limited to: charges for returned/bounced checks; charges for missed appointments without 24-hours’ notice; and any costs associated with the collection of your outstanding balance.

If you have any questions about your financial responsibility, you may contact our Billing Department at 718-998-9890.