Hospital Consent Form

Please click here to download a copy of the Hospital Consent form, print and bring it with you to your appointment, or complete the form below and submit it electronically. comodo_secure_226x142

  • Spring Valley Pediatrics Consent and Good Faith Estimate Notice Effective January 2022, the No Surprises Act requires health care providers that provide out-of-network care at in-network facilities to provide a good faith estimate of the out-of-network bill, options for in-network care, and a consent for patients/parents to sign who opt to receive out-of-network care at in-network facilities. When our pediatricians at Spring Valley Pediatrics perform hospital visits for newborns at Sibley hospital, we are providing out-of-network care at an in-network facility.
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  • Out-of-network provider: Spring Valley Pediatrics, PLLC (tax ID:53-0224276 ), and its doctors.

    Total cost estimate of what you may be asked to pay:
    ►Review your detailed estimate. See Page 4 for a cost estimate for each item or service you will get.
    ►Call your health plan. Your plan may have better information about how much you will be asked to pay. You also can ask about what is covered under your plan and your provider options.
    ►Questions about this notice and estimate? Call our Billing Office at (202) 966-1157
    ►Questions about your rights? Contact CMS, Centers for Medicare, and Medicaid Services, https://www.cms.gov/nosurprises or the Office of the Attorney General for the District of Columbia, OAG’s Office of Consumer Protection at (202) 442-9828, consumer.protection@dc.gov for more information about your rights under federal law.

    Prior authorization or other care management limitations
    Spring Valley Pediatrics is an out-of-network provider. We do not participate with insurance companies. Payment is due at the time of service. After payment and as a courtesy for our patients, our billing office may submit the bill for medical services to insurance companies on behalf of patients. We indicate to insurance companies that reimbursement from insurance companies should be made directly to patients. You may receive a check from your insurance company based on your individual plan for out-of-network reimbursement. Because we are an out-of-network facility, no prior authorization is required for our services.

    Understanding your options You can also get the items or services described in this notice from providers who are in-network with your health plan: A hospitalist pediatrician at Sibley Memorial Hospital is available to see your newborn.
    More information about your rights and protections:
    Contact CMS, Centers for Medicare and Medicaid Services, https://www.cms.gov/nosurprises or the Office of the Attorney General for the District of Columbia, OAG’s Office of Consumer Protection at (202) 442-9828, consumer.protection@dc.gov, for more information about your rights under federal law.
  • I am giving up some consumer billing protections under federal law. I will get a bill for the full charges for these items and services and may not receive reimbursement for these charges under my health plan. I got the notice either on paper or electronically, consistent with my choice. I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit. I am not obligated to receive the services described in this notice and can end this agreement by notifying the provider in writing before getting services.
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  • IMPORTANT: You do not have to sign this form. But if you do not sign, this provider or facility might not treat you. You can choose to get care from a provider or facility in your health plan’s network.
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