ATTENTION: This notice is being provided to you (or your legal representative) in order to comply with Virginia law (Va. Code § 32.1- 137.05), which requires every hospital, upon request of a patient scheduled to receive an elective procedure, test, or service or request of a patient’s legally authorized representative, to provide an estimate of the payment amount for which the patient will be responsible for such elective procedure, test, or service. The law also requires every hospital to provide written information about the patient's ability to request an estimate of the payment amount pursuant to the law.

As required by law, we are providing you with notice that if you have been scheduled to receive elective services at [health care facility], you have the ability to request an estimate of the payment amount for which you will be responsible for such elective services.

To obtain an estimate of the payment amount or if you have a question about this notice, please call (800) 849-0829.

If you are covered by insurance, consultation with your managed care plan/insurance company is recommended to determine if the elective service you are scheduled to receive is a covered service and what your actual out-of-pocket expenses will be after your benefits are applied, including any applicable cost-sharing requirements.