A. Except for a nonpreferred provider who is an on-call physician or a hospital-based physician, a nonpreferred provider who is a physician shall provide a copy of the disclosure set forth in §B of this regulation to each insured before performing a health care service for the insured in order to qualify for an assignment of benefits under a preferred provider insurance policy.
B. The disclosure text required by §A of this regulation shall be printed in at least 12 point type and shall read as follows:
Your doctor is not a part of your health insurer’s network. You may pay more for the services provided by your doctor because:
• Your doctor’s charge may be higher than the amount your health insurer will pay and, if so, you may be required to pay the difference; and
• Your coinsurance, deductible and out-of-pocket maximum may be higher because your doctor is not in your health insurer’s network.
Your doctor may charge you for services not covered under your health insurance contract.
Your doctor will provide you with the following information before performing the services for you:
• An estimate of the cost of the services;
• Any payment terms that apply; and
• Whether your doctor will charge you interest on any unpaid balance, and the amount of the interest, if any.
I, [patient’s name] __________________________ received the information above and authorize my health insurer to reimburse my doctor directly for the services provided [today’s date]_______________.”