In-Network and Out-of-Network Insurance Disclaimer

Insurances We Are In-Network With:

• Aetna

• Cigna

• Blue Cross Blue Shield

• Horizon NJ Health

• Medicare

• Medicaid (NJ Family Care)

• United Healthcare Community Plan

Even though your plan is not listed above, please be aware you may have out of network coverage to be used for your visit today. Our billing team is always available to further discuss your estimated responsibility for services rendered. For a full breakdown of your plan benefits, please reach out directly to your insurance company.

I hereby understand that Center for Pediatric Neuroscience, LLC is Out of Network with:

, my current Health Insurance Company. I knowingly and voluntarily chose to have:

provide healthcare services to me at Center for Pediatric Neuroscience on:

,with the full knowledge and understanding that he/she is not In-Network with my health benefits plan.