Notice and Consent Form

You may receive a Notice and Consent Form from out-of-network providers. These tell you about your rights and protections against unexpected out-of-network (surprise) medical bills, and your option to waive those rights.

By signing a Notice and Consent Form, you agree to give up rights that protect you from being balance billed. As a result, you could be charged more for your medical care.

This form is also known as a waiver.

This form is separate from other medical consent forms that your health care provider or facility may ask you to sign before your treatment begins.

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