Fair Patient Billing Act concerning Out-of-Network Providers Huntsville Memorial Hospital, in compliance with the Patient Billing Act” concerning out-of-network “Fair providers, would like to notify the patients of the following: You may receive separate bills for services provided by healthcare professionals affiliated with HMH. Some healthcare professionals may not be participating providers in the same insurance plans and networks as HMH You may have greater financial responsibility for services provided by healthcare professionals at HMH who are not under contract with your healthcare plan You should direct questions about coverage or benefit levels to your healthcare plan and certificate of coverage. Itemized bills are available upon request. If you are uninsured, you may be eligible for financial assistance under the terms and conditions the hospital offers to qualified patients. If you would like to ask questions, dispute your account, request an itemized statement, need assistance in making arrangements or need to speak with a patient financial services representative, please call With my signature, I understand that I am responsible for any charges that may be incurred, that are applied toward my deductibles or are considered out-of-pocket expenses, such as out-of-network bills or co-pays. SIGNATURE DATE/TIME
Fair Patient Billing Act concerning Out-of-Network Providers Huntsville Memorial Hospital, in compliance with the “Fair Patient Billing Act” concerning out-of-network providers, would like to notify the patients of the following: You may receive separate bills for services provided by healthcare professionals affiliated with HMH. Some healthcare professionals may not be participating providers in the same insurance plans and networks as HMH You may have greater financial responsibility for services provided by healthcare professionals at HMH who are not under contract with your healthcare plan You should direct questions about coverage or benefit levels to your healthcare plan and certificate of coverage. Itemized bills are available upon request. If you are uninsured, you may be eligible for financial assistance under the terms and conditions the hospital offers to qualified patients. If you would like to ask questions, dispute your account, request an itemized statement, need assistance in making arrangements or need to speak with a patient financial services representative, please call With my signature, I understand that I am responsible for any charges that may be incurred, that are applied toward my deductibles or are considered out-of-pocket expenses, such as out-of-network bills or co-pays. SIGNATURE DATE/TIME
Patient-Packet-english.docx