\NYUlapone

\NYUlapone \ N.., WE MC! CENTEA HansjOirg Wyss Department of Plastic Surgery 305 East 33rd Street New York, NY 10016 Thank you for choosing NYU FGP Plastic Surgery Associates for your healthcare needs. We appreciate you as a patient and intend to be as available and informative to you throughout your entire experience with us. We are providing you with an overview of common insurance terms and protocol so that you can better understand what your insurance coverage means. As a patient at our practice, you may be responsible for some out of pocket costs (all non-reimbursed apatsesfor health care required to bc paid by the enrollee or ilISUIrli pa sal) depending on your insurance coverage. The costs include, your co-payment (co-pav\ (a fixed amount that a subscriber pays to the health care provider fora specified service). your co-insurance (a shared cost provision by which covered members of a health plan pay for a perconagc of billed services, usually appliedafter the deductible has been met and in addition to any copayment), and your deductible (fixed amount that a member pays out of pocket for health care, in addition to premiums, before insurance coverage or reimbursements is calculatal)_ You are expected to pay your copav and any other pertinent payments at the time of your visit. We will inform you when you make your appointment with us whether we participate with your insurance or not. If we participate with your insurance, you will be using your in-network benefits. If we do not participate with your insurance, please be sure that your insurance has out of network coverage (benefits for treatment obtained from a nonparticipatingprovider). If you do decide to move forward with a surgical procedure with us, we will obtain a pre-certification (an a:whorl:tit:tam provided by your insurance company afrer a review of diagnosis and proposed treatment plans prior to treamsent). The precertification is not a guarantee of benefits or payment and the procedure must meet the medical necessity guidelines in order for your insurance to cover it. We can provide you with the procedure code(s) that corresponds to the procedure that is anticipated to be performed before your pouxlure takes place. You can contact your insurance company (by using the Member Services number located on the back of your insurance card) and provide them with the code(s) so that they can let you know what their reasonable and customary rate is. This will also allow the insurance company to provide you with an estimate of what your out of pocket responsibility may be based on your insurance benefits. Please note that these codes arc not guaranteed to be billed until after the procedure is performed; they might change if the physician deems necessary while performing the procedure. There is also a post op period associated with your procedure. This is a pre-set amount of time in which you will not be charged for any follow up office visits that are related to the procedure performed. • The post-operative period for most minor procedures that are performed in the office is 10 days from the date of service. • The post-operative period for most surgical procedures performed in the hospital is 90 days from the date of service. However, any type of procedure, injection, x-ray. or office visit regarding a separate issue, performed within these 90 days, is billable to your insurance company and a copayment, coinsurance, or deductible may apply once the claim is processed per the insurance. Only post-operative office visits alone are not billable. After the 10 or 90 day period, all visits arc billable in full. INTIAL THAT I HAVE READ AND UNDERSTAND ALL ABOVE STATED EFTA00313912