Disclaimer

This good faith ESTIMATE should not be relied on as the final out-of-pocket cost for services as your final cost will vary based upon your specific needs at the time of the service, including additional treatments or services deemed necessary by the physician and/or additional information provided by your insurer.

This good faith ESTIMATE does not include bills from medical specialists, including by not limited to: physician charges, anesthesiology charges, radiologist reading fees and pathologist fees. Charges from these medical specialists will be billed separately to you.

If you are requesting a good faith ESTIMATE for a surgical procedure, the good faith ESTIMATE will not include:

• Pre-Procedure Office Visits
• Post-Procedure Office Visits
• Diagnostic Testing

If you have met all or part of your deductible or maximum out-of-pocket expenses, the actual amount you owe may be different.

The estimated cost is not a guarantee of insurance coverage. Please check with your insurance company if you need help understanding your benefits for the service chosen.

Final determination of eligibility and services covered are determined at the time the claim is processed by the insurance company. Any services determined non-covered by your plan are your responsibility to pay.

This good faith ESTIMATE is intended only for the use of the intended recipient. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or action taken in reliance on the contents of these documents is strictly forbidden.

I HAVE READ AND UNDERSTAND THE ABOVE LIMITATIONS AND I FULLY UNDERSTAND THIS IS ONLY A GOOD FAITH ESTIMATE.