Practice Information

MANHATTAN SPECIALTY CARE

Notice of Health Care Plan Participation, Hospital Affiliations, and Coordination of Care/Referrals to Other Health Care Providers

I hereby acknowledge the following:

• I have received this notice from Manhattan Gastroenterology, PC d/b/a Manhattan Specialty Care (the “Practice’’) of the health care plans in which the Practice and all Practice physicians and other practitioners are participating providers, as well as the hospital affiliation(s) of all Practice physicians/practitioners, as set forth in Appendix A.
• I am aware that I can find up-to-date information about my physician’s/practitioner’s health care plan participation and hospital affiliation(s) on the Practice’s website at: www.manhattanspecialtycare.com
• I am aware that some of the Practice’s services are provided on an out-of-network basis:
  • Physician Services. I acknowledge that I have been made aware certain physicians as well as anesthesiologists of the Practice may not participate in my health care plan. I understand that if I receive services from a non-participating physician, I may be financially responsible for certain out-of-pocket costs that my health care plan does not cover.
  • Radiology and Laboratory Services. I am aware that the Practice has an in-office laboratory and that the Practice can perform certain laboratory testing, which may be provided on an out-of-network basis. Further, I am aware that the Practice performs certain radiology services (for example, ultrasounds) which may be on an out-of-network basis. I am aware that, to the extent my physician/practitioner refers a specimen to the Practice’s in-house laboratory, or performs radiology test(s) at the Practice, I may be responsible for certain out-of-pocket costs that my health care plan does not cover. I am aware that I may request that the Practice refer my specimen(s) to an outside lab and/or refer me to another radiology provider that does participate in my health care plan.
• In connection with the Practice’s out-of-network physician services, anesthesiology services, radiology services and/or laboratory services, I am aware that I may request an estimate of the amount of charges for these services by calling the Practice, and upon such request, I will receive a written estimate of the charges that I will be billed for the service(s) (absent unforeseen medical circumstances that may arise).
• I acknowledge that my physician/practitioner may coordinate with or refer to other health care providers for certain anesthesiology, laboratory, pathology, radiology and/or assistant surgeon services. I acknowledge that the Practice has provided me with the names, addresses and phone numbers of these other health care providers, as set forth in Appendix B of this notice,  and that I may contact these health care providers to find out if they participate in my health care plan or product.
• If I have any questions about the Practice’s health care plan participation, my physician’s/practitioner’s health care plan participation, billing questions, or if I would like to request information about the estimated charges for out-of-network services, I can call (212) 427-8761.

APPENDIX A

Manhattan Women’s Health and Wellness, d/b/a Manhattan Specialty Care, d/b/a Manhattan Primary Care/Manhattan  – Physician Health Care Plan Participation and Hospital Affiliations

GYNECOLOGY

RADIOLOGY

PATHOLOGY

APPENDIX B

Manhattan Gastroenterology, PC, d/b/a Manhattan Specialty Care, d/b/a Manhattan Primary Care – Coordination/Referrals to Other Health Care Providers

LABORATORY SERVICES:

RADIOLOGY SERVICES:

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