Off Campus Medicare Outpatient Coinsurance Notice

To our Medical patients:

Medicare regulations require us to provide you with a notice of your potential financial liability for the hospital service(s) you will receive.

We are required to advise you that because the services are furnished by the following practices:

• Mountain Valley Surgery
• Sylva Orthopaedic Associates
• WNC Pediatric and Adolescent Care
• Center for Family Medicine
• Western Carolina Pulmonary and Sleep Consultants
• Sylva Medical Center
• Carolina West Sports Medicine
• Mountain Care Urology
• Haywood Women's Medical Center
• Haywood Medical Associates
• Western Carolina Cardiology
• WNC Hospitalist Service
• Waynesville Family Practice
• Haywood Surgical Associates
• Blue Mountain Urology

all departments of MedWest-Harris or MedWest-Haywood, you will incur a coinsurance liability to the hospital that you would otherwise not incur if the services were furnished in an entity that is not hospital-based. At the time you are seen in one of our offices we can provide you with information on the estimated amount of your coinsurance liability:

The actual amount of our patient’s coinsurance liability may be different from the estimate provided in the office. Actual coinsurance liability will be based on the services that you receive and also subject to final determination by the Medicare Program.

If you are enrolled in a state medical assistance program such as Medicaid, your coinsurance may be reduced or eliminated by law.

Your coinsurance liability for hospital services is separate from the Medicare coinsurance liability that you may owe for any physician or professional service provided to you in conjunction with hospital services.