Billing Rights Summary

Our acceptance of any payment marked with a restrictive legend or otherwise marked "paid in full" will not operate as an accord and satisfaction without our express prior written approval.
If you believe this statement is incorrect, or if you need additional information, contact us by in writing or by phone. The billing inquiry number is listed on the front. We must hear from you no later than 60 days after the initial statement. You may telephone us, however doing so will not preserve your rights.

When you contact us, please provide the folowing information.

• Your name and account number
• Describe the error or problem

Please pay in U.S. Dollars. Checks should be written from a U.S. Bank. If a check is written from a Foreign Bank, add $35.00 for U.S. Bank processing fees or pay by an American Express Money Order.

Team Health will charge a processing fee (added to the balance due on this account) for any check which is returned by the bank "Non-Sufficient Funds"/"NSF". This fee will cover the expense incurred by Team Health for Bank Fees, extra processing to correct the account balance and additional statement processing.

We are required by applicable federal and state law to maintain the privacy of your health information. Therefore, if you contact us regarding this statement, we will ask you to provide certain information to identify yourself. Please notify us if you want another person to act as your representative regarding this statement or your account. Your representative will also be asked to provide specific identifying information related to you. We will only discuss information regarding your account that is directly relevant to the payment of your account, e.g., providing the account balance, taking insurance information, and setting up budget plans. We will not discuss any health information related to diagnosis or medical treatment with any caller, including you. Since we do not maintain your original medical record, all requests for information in your medical records should be made directly to the treating facility.