No Surprises Act

No Surprises Act - I am required to provide this!

This document describes your protections against unexpected medical bills.
It also asks if you’d like to give up those protections and pay more for out-of-network care. 

IMPORTANT: You aren’t required to sign this form and shouldn’t sign it if you didn’t have a choice of health care provider before scheduling care. 

You can choose to get care from a provider or facility in your health plan’s network, which may cost you less, then seeing an out of network provider. 

You’re getting this notice because this provider, Trinity Wellness Group, LLC,  IS NOT  in your health plan’s network and is considered out-of-network. This means the provider or facility doesn’t have an agreement with your plan to provide services. Getting care from this provider or facility will likely cost you more.  

If your insurance plan covers the item or service you’re getting, federal law protects you from higher bills when:  

• You’re getting emergency care from an out-of-network provider or facility, or  
• An out-of-network provider is treating you at an in-network hospital or ambulatory surgical center without getting your consent to receive a higher bill.  

Ask your health care provider  if you’re not sure if these protections apply to you.  
If you sign this form, be aware that you may pay more because:  

• You’re giving up your legal protections from higher bills.  
• You may owe the full costs billed for the items and services you get.  
• Your health plan may or might not count any of the amount you pay towards your deductible and out-of-pocket limit. Contact your health plan for more information.  
  
  Before deciding whether to sign this form, you can contact your health plan to find an in-network provider or facility. If there isn’t one, you can also ask your health plan if they can work out an agreement with this provider or facility (or another one) to lower your costs.
  
  Please sign  your name and today's, that you have received the notice of "NO SURPRISES ACT" (You may also will receive this via "Ivy Pay" on your first invoice)