Richard Eller, MD, PA

• Beginning on the effective date listed above, services provided by me may be considered out-of-network by your health insurance plan.

• You will be responsible for payment at the time services are rendered unless other arrangements have been made in advance.

• Depending on your health plan, you may have out-of-network benefits that could reimburse you for some portion of the charges you pay to the practice.

• Coverage, reimbursement, deductibles, coinsurance, and eligibility for out-of-network benefits are determined solely by your health insurance plan. You should contact your insurer directly to determine your available benefits and any requirements that may apply.

As a courtesy, the practice will provide you with documentation of your visit, including receipt and, when applicable, information commonly required for insurance reimbursement requests.

However, after the effective date above:

• The practice will not submit claims to commercial insurers on your behalf.

• The practice will not participate in claim appeals, prior authorizations, coverage disputes, reimbursement disputes, or other communications with your insurer except as otherwise required by law.

• If you choose to seek reimbursement from your insurer, you will be responsible for submitting any claim forms and supporting documentation directly to your health plan.

You have the right to continue receiving services from this practice or to seek care from another provider who participates in your insurance network. If you choose to transfer your care, we will cooperate with any lawful request for records and information as permitted by applicable law.