Notification of Non-Participation with Patient’s Health Plan
Based on the information I have provided to Ferrell Hospital, it has been determined that Ferrell Hospital is not a participating provider with my health plan, and I have been so informed.I understand by utilizing the services of a non-participating hospital for anything other than emergency services or services approved by my health plan in advance, those services may be covered at my health plan’s out-of-network level of benefits, which may be substantially less than my in-network level of benefits.
INSURANCE COMPANY NAME: __________________________________________
I have been informed of Ferrell Hospital’s non-participating status and elect to receive the service(s) for which I am scheduled.
Signature of Patient (or Personal Representative/Agent) __________________________________
Date _________________
Printed Name of Personal Representative/Agent Relationship to Patient ____________________________
Witness________________________________________________