This good faith 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 good
faith 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.
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 good
faith 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. To obtain a fully personalized good faith ESTIMATE
contact Customer Service at 706-213-2593. The final price may be
higher or lower based on actual services rendered at time of
appointment. It is advised that you contact your health insurer for
most accurate individual payment responsibilities and to confirm any
applicable remaining deductible balances. EZCOST is optimized to run
in Chrome, Firefox, and Safari. Please use one of these browsers for
the best user experience. I HAVE READ AND UNDERSTAND THE ABOVE
LIMITATIONS AND I FULLY UNDERSTAND THIS IS ONLY A GOOD FAITH
ESTIMATE.
