Disclaimer

This out-of-pocket 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 out-of-pocket 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 out-of-pocket ESTIMATE for a surgical procedure, the out-of-pocket 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 out-of-pocket 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.

If you are requesting a out-of-pocket ESTIMATE for any of the services below, please use the contact information provided in order to obtain a complete out-of-pocket ESTIMATE.

Kettering Network Radiologist Inc. (KNRI) 844-306-2407

Hospitalist Care Group (Inpatient Stays) 260-344-4035

Professional Emergency Physicians (Emergency Room Physician Visits) 260-482-4440

Associated Anesthesiologists of Fort Wayne (Anesthesia Administration) 260-435-6732

South Bend Medical Foundation (Pathology) 1-800-950-7263

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I HAVE READ AND UNDERSTAND THE ABOVE LIMITATIONS AND I FULLY UNDERSTAND THIS IS ONLY AN ESTIMATE.

IMPORTANT INFORMATION REGARDING USE AND LIMITATIONS OF THIS ESTIMATE

1. To obtain the most accurate estimate of patient out of pocket costs, it strongly recommended that patients contact their insurer to request an estimate or Cameron Memorial Community Hospital at 260-667-5128. To obtain the most accurate estimate possible, the patient's insurance information, if any, as well as a specific description of the service requested, preferably a physician's order, are necessary.
2. Actual cost to the insurer and/or patient, as well as the out-of-pocket (OOP) amount for which a patient will be directly responsible, are determined by several factors and are not in the exclusive control of Cameron Memorial Community Hospital, including, but not limited to:
   1. The payment methodology applied by the patient's insurance, which may include commercial health insurance, automobile insurance, workers compensation insurance, or government health insurance coverage, e.g. such as Medicare, Medicaid, or Veterans Administration, etc.
   2. These insurance payment methodologies, including the prospective payment methodologies applied by Medicare and Medicaid, frequently are not directly related to fee schedules charges or a percentage of charges,
   3. The patient's level of coverage, particular insurance plan (e.g. HMO, PPO, etc.), network participation status of each provider, and the patient's currently outstanding benefits within the patient's plan benefit package, including co-pays, co-insurance, remaining deductible, and OOP maximum,
   4. The most appropriate services, as determined by the patient's treating and/or referring physician(s) at the time they receive the services, and acknowledging that the patient's actual medical need, as determined be the treating physician at the time of service, may be substantially different than the anticipated medical need prior to provision of the medical treatment or services.
   5. Although estimates are available through Cameron Memorial Community Hospital for most scheduled service, the nature of healthcare, including the factors described above, dictates that the appropriate level of care, and thus patient OOP cost of that care, frequently cannot be accurately determined until the care has actually been provided.
   6. The actual cost for which the insurance and/or patient may be responsible are often, although not always, significantly less than the total charges posted to a patient's account, and thus, estimating payer cost or patient OOP responsibility using a fee schedule alone will not produce an accurate estimate.
   7. Patients with no insurance coverage are eligible for a minimum of a 39% discount off of standard charges at Cameron Memorial Community Hospital; however, depending on the type of services received, timing of payment, and patient's financial need, pre-payment discounts, prompt-payment discounts, packaged pricing, as well as financial assistance may be available to further lower an uninsured patient's actual OOP expenses.

BY DOWNLOADING AND ACCESSING THIS OUT-OF-POCKET ESTIMATE, YOU ARE ACKNOWLEDGING THE FOLLOWING:

• I have read and am aware of the above information, the contextual limitations of the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator, and recognize that the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator cannot be used as a single source for determining actual cost to any payer, including insurers, employers, or patient out-of-pocket responsibility, and if such single service determination is attempted, the information will be out-of-context and therefore, incomplete and inaccurate.
• If I am a non-patient, third-party, I acknowledge that I have read and am aware of the above information, the contextual limitations of the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator, and recognize that the Cameron Memorial Community Hospital Out-of-Pocket Cost Estimator cannot be used as a single source for determining actual cost to any payer, including insurers, employers, or patient out-of-pocket responsibility, and if such single service determination is attempted, the information will be out-of-context and therefore, incomplete and inaccurate. I further acknowledge that if I or my organization republish, post online, or otherwise re-communicate this information to another party and hold-out these fee schedules to the sole determining factor in establishing payer cost or patient out-of-pocket responsibility, without providing the contextual limitations described above, I risk misleading the consumers of such information due to the limitations detailed in this disclaimer. If my or my organization's intent is to aid a payer or patient in determining actual payer cost or patient out-of-pocket responsibility, I acknowledge that this intent is most accurately and effectively achieved by recommending that such individuals contact their insurer or Cameron Memorial Community Hospital at 260-667-5128.