Out of Network – Non Participating Provider

TO: OUT OF NETWORK MEMBERS
RE: NON-PARTICIPATING PROVIDER
DATE OF SERVICE: ______________________________________________
PATIENT: ______________________________________________

Thank you for scheduling your procedure at Dry Creek Surgery Center. Your physician designed this facility with you in mind, and recommended treatment here to provide you with the highest level of patient care. We are proud to serve you and are committed to meeting your healthcare needs in a state of the art environment, with a first rate staff and excellence in patient satisfaction.

Although Dry Creek Surgery Center is not currently a participating provider with your Insurance Plan, we strive to give our patients the best possible value for their health care dollar. While we cannot waive the patient responsibility required by your health plan, we are able to extend a significant discount if the estimated cost of your procedure is paid in advance. We also offer a discounted rate if the cost of your procedure is paid within 30 days or 60 days from your date of service. The same discounts are extended to your health plan as well. Our discount program allows us to provide access to superior quality care to all patients in the community, regardless of insurance type, at a cost-effective rate for you, your family and your health plan.

A member of our staff will call you approximately one week prior to surgery to discuss pre- operative orders and your insurance coverage. We will provide you with a cost estimate for your upcoming procedure, and the amount of payment due at the time of service, as well as payment options available. Once you are fully informed of the Financial Policies, you will be asked to agree in advance as to how you would like to pay for services, and all relevant forms will be presented for signature upon check in. We are confident in our competitive pricing, and are willing to match a lower price you are offered from an area hospital, if you wish to provide a copy of their estimate.

We will submit a claim to your insurance company on your behalf, and it is possible that the insurance payment for your visit will be sent directly to you. We ask that you please endorse the check over to the facility, and mail it, along with your Explanation of Benefits. Compliance with this request will allow us to process the payment to your account quickly and efficiently, and make any necessary adjustments.

If you have any questions or concerns, please do not hesitate to call our billing office at 1-866-915-7788 between the hours of 9:00 – 5:00 Mon-Fri.

We look forward to serving you, and appreciate being your preferred choice for surgical care.

Dry Creek Surgery Center
125 Inverness Drive East Suite 150
Englewood, CO 80112