No Surprises Act Disclosure Notice

Your Rights & Protections Against Surprise Medical Bills

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No Surprises Act Disclosure – Surprise Medical Bills

Raleigh Hearing and Tinnitus Center is committed to complying with the federal No Surprises Act and NC state regulations involving surprise billing and balance billing. This form contains various disclosures pursuant to these laws.

Your rights and protections against surprise medical bills

When you are a private pay patient or get treated by an out-of-network provider, you are protected from surprise billing or balance billing.

You are protected from surprise billing in certain circumstances:

  • Emergency services. If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent to be balanced billed for these post-stabilization services. The No Surprises Act defines which types of services fall into these categories.
  • Certain services at an in-network hospital or ambulatory surgical center. When you receive services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent. You’re never required to give your consent. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
  • Uninsured/Self-Pay Patients. Some provisions of the No Surprises Act are inapplicable to patients who are uninsured or who are self-pay. Instead, uninsured/self-pay patients are generally entitled to a “good faith estimate” for non-emergency services.

If you believe you’ve been wrongly billed, first contact the provider that sent you the bill and your health plan for an explanation. If they can’t resolve your concerns or for more information, you can contact the

United States Department of Health and Human Services ( regarding the federal law.


the North Carolina Department of insurance (

Consumer Services Division: 855-408-1212