For: Hospital Charges $ 54,000 for: Physician Charges

Ophthalmic Exams Under Anesthesia. Possible 3 Unilateral Intravitreal Melphalan Injections. Possible Treatment: Cryotherapy or Photocoagulation, At Each Exam Under Anesthesia. Neurology Medical Oncology Clinical Visits Associated With Retinoblastoma Treatment.

While we cannot provide you with the exact costs for this plan of treatment, we estimate the cost will be approximately $ 95,000(which would be deposited as follows):

for: Hospital Charges $ 54,000 for: Physician Charges

Please be aware that this is only an estimate. It was formulated based on the treatment plan provided to us as noted above. In the event your treatment plan includes an inpatient stay; the above noted amounts include semi-private room accommodations. If this plan differs from what was explained to you please let us know immediately. Also, please take note that the above noted treatment plan may not take into consideration other possible treatments, modalities of care or changes which may be deemed medically necessary. It reflects average costs associated with care. Therefore actual charges could exceed the amounts noted above. Additional deposits will be needed for additional services.

Second Opinion does not obligate you to obtain treatment or services at MSKCC; nor does it obligate MSKCC to provide care or services.

Memorial Sloan-Kettering Cancer Center requires payment in full; in advance – prior to obtaining any treatment or services. Therefore, payment of $ 95,000 is required in advance prior to obtaining the treatment noted above.

Memorial Sloan-Kettering does not bill foreign insurance companies; does not accept letters of guarantee and does not provide discounts.

We can not accept any personal checks as payment towards treatment.

Patients are responsible for all costs related to their treatment at Memorial.

The MSK International Center alerts the Department of Homeland Security, Bureau of Citizenship and Immigration Services when patients attempt to become a “public charge” under section 212 (a) (4) of the Immigration and Nationality Act.

In the event that there your actual charges do exceed the deposit, you will be responsible for the difference. If actual charges fall below the amount paid, a refund will be initiated.

Should you proceed with treatment at our hospital – MSKCC will provide you with Hospital and Physician Statements that itemize the medical care and services provided. These statements are mailed out on a regular basis.

The New York State Healthcare Reform Act requires that patients pay a surcharge on any hospital charges that are not covered by insurance that is being billed directly by Memorial Hospital. You will see this noted as “New York State Surcharge” on your Hospital (blue and white) statements. The estimate of charges provided herein attempts to reflect the impact of this surcharge, but is subject to the guidelines described above with regard to actual and estimated charges.

Please call your Guest Services Coordinator at 212.639.4900 with any questions or concerns.

PA ____

Memorial Sloan-Kettering Cancer Center Hospital

By signing below, I hereby authorize the Memorial Sloan-Kettering Cancer Center to charge my Credit Card for any physician visits, procedures, and tests, treatment modalities and/or services that may be provided at Memorial Sloan-Kettering Cancer Center.

For your protection, Credit Card Information (your Account Number/Signature) is not kept on file at the International Center. Therefore, we will request your signatory approval for each charge to your credit card.

Indicate type of credit card to be charged (We do not accept Debit Cards)

Date: 2015-12-11; view: 441