Billing Information

All patients and prospective patients at Oxford Surgery Center will receive and have the
right to receive a personalized, written estimate of the services and procedures
performed.

Service bundle information is a non-personalized estimate of costs that may be incurred
by the patient for anticipated services, and actual costs will be based on services
provided to the patient.

All patients and prospective patients have the right to request a personalized estimate
from the facility.

Oxford Surgery Center does not have or participate in any financial assistance or charity
care.

Patients should contact their provider to ensure that Oxford Surgery Center participates
in their insurance plan or health maintenance organization (HMO).
Oxford Surgery Center will collect all fees pertaining to the services being provided prior
to surgery. Oxford Surgery Center patients may use cash, checks, or major credit cards
to pay these fees. If payment is not received prior to the surgery, Oxford Surgery Center
has the right to cancel or reschedule the surgery. Checks returned for insufficient funds
will be sent to collections.

Health insurers and health maintenance organizations (HMO) contracted with Oxford
Surgery Center below.
Medicare www.medicare.gov
Aetna – www.aetna.com
BCBS – www.bcbs.com
United Healthcare – www.uhc.com

This Good Faith Estimate does not include any unknown or unexpected costs that may
arise during treatment. Additional charges can be incurred if complications or
exceptional circumstances occur. Federal law allows you to dispute (appeal) the bill if
this happens.

IF YOUR BILL EXCEEDS YOUR GOOD FAITH ESTIMATE, YOU HAVE THE RIGHT
TO DISPUTE THE CHARGES.

You may contact the health care provider or facility listed and tell them the billed
charges exceed the Good Faith Estimate. You can ask them to update the bill to match
the Good Faith Estimate, negotiate the bill, or ask if financial assistance is available.
You may also start a dispute resolution process with the U.S. Department of Health &
Human Services (HHS). If you choose to use the dispute resolution process, you must
start the process within 120 calendar days of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute
agrees with you, you will have to pay the amount on the Good Faith Estimate. You will
have to pay the higher amount if the agency disagrees with you and agrees with the
health care provider or facility. For questions or more information about your right to a
Good Faith Estimate, go to www.cms.gov/nosurprises or call 1-800-985-3059.

Please keep a copy of your Good Faith Estimate in a safe place and/or take pictures of
it. You will need it if you are billed for a higher amount than estimated.