Transcription of 19 - Out of network waiver form - Hand & Wrist Center
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19 - Out of network waiver form - Hand & Wrist Center
OUT OF network PROVIDER waiver FORM I, _____, have been advised that Dr. Ross Nathan and/or George A. Macer, , are not an in- network provider for my insurance plan _____; therefore, services provided to me, and billed by The Hand and Wrist Center and the billing service, will be considered out-of- network services. Under this acknowledgement, I understand that my insurance carrier may pay for services rendered at a lower rate compared to those considered as in- network . I agree to pay 50% of the anticipated total charges today, and on each day of service thereafter.
OUT OF NETWORK PROVIDER WAIVER FORM I, _____, have been advised that Dr. Ross Nathan and/or George A. Macer, M.D., are not an “in-network provider” for my insurance plan
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