Explanation of Financial Responsibility
Non-Contracted Insurance Plans

Dear Patient,

We are pleased that you have chosen the Rinehart Center for Reproductive Medicine, for your fertility care. Our Center will make every effort possible to coordinate your care with you. This support includes our commitment to answering your questions about your insurance reimbursement and payment for your treatment.

Based upon the information that you supplied to us, we determined that you insurance plan is not one of your contracted plans. Fortunately, as and out-of-network provider, we often help out patients get significant reimbursement for the cost of their fertility care. Our staff and billing specialists will do everything that they can to help reduce your payment portion. Your help in providing us with timely and accurate information such as referrals, secondary insurance information, and changes in your health plan will help us.

Your responsibility to pay for services at your Center (your “patient portion”) is determined by insurance plan. As an out-of-network patient, you will have a patient portion to pay at each visit. This fee will be 30% (thirty percent) of the total charges for all services provided to you at that office visit. We will submit the remaining charges to your insurance plan. Any changes not reimbursed by your plan will be billed to you. In some Cases, if your plan pays for more changes than expected, your patient portion may be adjusted. Changes in the patient portion can only be made after your insurance plan clearly states what it will pay for your treatment. This process generally takes more than one billing cycle.

You may call our billing specialist at 800-423-7380 if you have any further questions about your out-of-network status with our Center. We look forward to working with you on your fertility issues.

The Staff of the Rinehart Center for Reproductive Medicine