-™ Hansjorg Wyss Department of Plastic Surgery New York, NY 10016 — a 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 expenses for healthcare required tobe paid by the enrollee or insured person) depending on your insurance coverage. The costs include, your co-payment (co-pay) (a foxed amount that a subscriber pays to the health care provider for a specified service), your co-insurance (a shared cost provision by which covered members of a health plan pay for a percentage of billed services, usually applied after the deductible has been met and in addition to any co-payment), 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 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 non- participating provider). If you do decide to move forward with a surgical procedure with us, we will obtain a pre-certification (an authorization provided by your insurance company after a review of diagnosis and proposed treatment plans prior to treatment. The precertification is hot 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 procedure 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 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 are 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 dure. This is a pre-set amount of time in which will noc be charged for any follow up office visits chat are related to the procedure sefoc cd “ ° 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 st date of service. However, any type of procedure, injection, x-ray, or office visit regarding a separate issue, performed within INTIAL THAT I HAVE READ AND UNDERSTAND ALL ABOVE STATED EFTA00313912