Financial Policy

Your physician has chosen to perform your endoscopic procedure(s) at the Kips Bay Endoscopy Center LLC [KBEC]. KBEC is a freestanding Ambulatory Surgical Center [ASC] subject to New York State regulations. It is not associated with your doctor's office and has separate financial and billing policies and procedures.

KBEC will charge you for its facility and anesthesia services. Please understand that you are responsible for paying your bill(s) in connection with your treatment at the time of registration. You will also receive a separate bill from your physician for your endoscopy procedure, the anesthesia service and a separate bill for applicable laboratory services. Your physician's, anesthesiologist's and laboratory charges are independent of the KBEC charge.

The following is a statement of our Financial Policy that we require you read and sign prior to your treatment at KBEC.

While your physician may participate in your insurance plan, KBEC may or may not participate with your insurance plan. Prior to the date of your procedure, please verify the details of your insurance coverage with your insurance carrier. To further understand KBEC's policy, please review the following:

• 1. If KBEC participates with your insurance plan, the fees for your services will be billed to your insurance plan. However, you are responsible for the payment of your in-network deductible, co-payments and/or co-insurance at the time of your procedure. These fees are mandated by your insurance carrier and cannot be waived. Please contact your insurance carrier to obtain information for the type of benefit you have for an Ambulatory Surgery Center setting. The co-payment amounts differ from that of a physician's office. Please be prepared to pay these fees at the time of your procedure. If you are unable to pay in full at the time of your visit, we expect 50% of your obligation with your insurance and a modest payment plan, not to exceed a year. We accept cash, checks, Visa, MasterCard, Discover, AMEX, or DEBIT cards with a Visa or MasterCard logo. You may also use your Flexible Spending Account (FSA) or Health Savings Account (HSA) to pay your debt.
• 2. If KBEC does not participate with your insurance plan, KBEC will bill your insurance plan. If you have "out-of- network" coverage, your insurance plan may cover a part of this charge. You are responsible for the payment of your deductible and co-insurance as well as any unpaid balance and KBEC will bill you accordingly. If you have no "out-of- network" coverage, you will receive a bill from KBEC for the facility fee and anesthesia fee. You are required to make payment arrangements prior to your procedure. You may also receive a bill for laboratory services if the physician collects biopsy specimen's during the procedure.
• 3. KBEC participates with the Medicare program. If you have Medicare coverage, you will be responsible for payment of the unmet deductible and the remaining 20 percent of the approved charge. Please be prepared to pay these fees at the time of your procedure. We accept cash, checks, Visa, MasterCard, Discover, AMEX, or DEBIT cards with a Visa or MasterCard logo.
• 4. Some insurance plans will send KBEC's facility and anesthesia payments directly to you. If you receive the payments for the services you received at KBEC, you are responsible for forwarding the check directly to KBEC. It is your responsibility to ensure the Center is paid the amount that has been sent to you plus any remaining balance. Be advised that not remitting the payments to KBEC constitutes a breach of contract and KBEC will pursue all legal remedies available to it to obtain such payments.
• 5. For private paying patients, please contact the Center to discuss your payment options.
• 6. Return Check Fee. If you make payment to the Center by check and it is returned by the bank for any reason, you will incur a fee of $30.00.