Patient Application Form - Nys Idr For Emergency Services And Surprise Bills - Nys Department Of Financial Services

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PATIENT APPLICATION
NEW YORK STATE INDEPENDENT DISPUTE RESOLUTION (IDR) FOR EMERGENCY
SERVICES AND SURPRISE BILLS
If you are uninsured, or you have health insurance coverage through your employer and your employer
self-insures, you may dispute: (1) A bill for emergency physician services in a hospital; or (2) a surprise bill
for non-emergency physician services in a hospital or ambulatory surgical center if your provider did not
give you all required information about your care. Complete this form and send it to the NYS Department
of Financial Services, Consumer Assistance Unit/IDR Process, One Commerce Plaza, Albany, NY 12257.
For help call 1-800-342-3736 or e-mail IDRquestions@dfs.ny.gov.
You do not need to complete this form if you have coverage through an HMO or insurer subject to NY law
(coverage that is not self-insured). If you receive a surprise bill, you can sign an assignment of benefits
form to permit your HMO or insurer to pay your provider directly. Your HMO or insurer will dispute the bill
for you and you will only have to pay your in-network cost-sharing. If you receive a bill for emergency
services, contact your HMO or insurer. You will only have to pay your in-network cost-sharing for
emergency services.
COMPLETE THE FOLLOWING
1. Patient Name: ________________________________________________________________________
2. Patient Address: ______________________________________________________________________
3. Patient Phone Number: (____)___________________ E-mail Address: _________________________
4. Health Plan (if applicable):______________________________________________________________
5. Patient’s Health Plan ID Number (if applicable): ____________________________________________
6. Health Plan Address (if applicable):_______________________________________________________
7. Health Plan Phone Number: (_____)__________________Fax Number: (_____)___________________
8. Provider Name: _______________________________________________________________________
9. Provider Address: _____________________________________________________________________
10. Provider Phone Number: (______)____________________Fax Number: (______)_________________
11. What type of bill are you disputing? (Please check one.)
[ ] Emergency Services
[ ] Surprise Bill for Other than Emergency Services
12. Date(s) of Service: _____________________________________________________________________
13. Time and Place of Service: ______________________________________________________________
14. The fee charged by the provider (include a copy of the bill): __________________________________
15. If applicable, the amount your health plan paid (include a copy of the notice or denial):___________
16. IDR Fee: Check one if you are uninsured or you are covered under employer self-insured coverage.
[ ] I agree to pay the IDR fee up to $325 if the IDR determines my physician’s fee is reasonable. If there is
a settlement between me and my physician I agree to pay half of the IDR fee. (If the IDR determines your
physician’s fee is not reasonable, your physician will pay the IDR fee.)
[ ] Payment of the IDR fee is a financial hardship to me. My household income is $__________________
and the number of people in my household is: ________________________________________________
(Fill in the above information and attach copies of your household’s most recent pay stubs.)
 

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