(1) Subject to subsection (2), a nonparticipating provider who is providing a health care service to a nonemergency patient shall provide the disclosure described in subsection (3) to the nonemergency patient at the earliest of the following:

    (a) If the health care service was scheduled and is being provided in a health facility described in section 24502(7)(a), (b), (c), (e), or (f), at least 14 days before providing the health care service or, if the health care service will be provided within 14 days after scheduling the health care service, within 14 days.

    (b) If the health care service is being provided in a health facility described in section 24502(7)(d), at the time of the nonparticipating provider’s first contact with the nonemergency patient regarding the health care service.

    (c) During 1 of the following:

    (i) A presurgical consultation for the health care service.

    (ii) A scheduling or intake call for the health care service.

    (iii) A preoperative review for the health care service.

    (iv) Any other contact occurring before a health care service that is similar to a contact described in subparagraph (i), (ii), or (iii).

    (2) A nonparticipating provider shall not provide the disclosure described in subsection (3) to a nonemergency patient at the time of the nonemergency patient’s admittance to a health facility described in section 24502(7)(a), (b), (c), (e), or (f), or at the time of preparing the nonemergency patient for a surgery or another medical procedure.

    (3) The disclosure required under subsection (1) must be in not less than 12-point type and in substantially the following form:

    “Your health benefit plan may or may not provide coverage for all of the health care services you are scheduled to receive or the providers providing those services. You may be responsible for the costs of the services that are not covered by your health benefit plan.

    The nonparticipating provider must provide a good-faith estimate of the cost of the health care services to be provided. A good-faith estimate does not take into account unforeseen circumstances, which may affect the cost of the health care services provided.

    You also have a right to request that the health care services be performed by a provider that participates with your health benefit plan, and may contact your carrier to arrange for those services to be provided at a lower cost and to receive information on in-network providers who can perform the health care services that you need.

    I have received, read, and understand this disclosure.

    __________________________________________________ _________

    (Patient or patient’s representative’s signature) (Date)

    __________________________________________________

    (Type or print name of patient or patient’s representative)”.

    (4) A nonparticipating provider shall do all of the following:

    (a) Complete the disclosure described in subsection (3) and, after completing the disclosure, obtain on the disclosure the signature of the nonemergency patient, or that patient’s representative, acknowledging that the nonemergency patient, or that patient’s representative, has received, has read, and understands the disclosure.

    (b) Retain a copy of the disclosure required under this section for not less than 7 years.

    (c) Provide the nonemergency patient or that patient’s representative with a good-faith estimate of the cost of the health care services to be provided to the nonemergency patient.

    (5) Except as otherwise provided in section 24513 and subject to subsection (6), a nonparticipating provider who fails to provide the disclosure as required under this section shall submit a claim to the nonemergency patient’s carrier within 60 days after the date of the health care service and shall accept from the nonemergency patient’s carrier, as payment in full, the greater of the following:

    (a) Subject to section 24510, the median amount negotiated by the nonemergency patient’s carrier for the region and provider specialty, excluding any in-network coinsurance, copayments, or deductibles. The nonemergency patient’s carrier shall determine the region and provider specialty for purposes of this subdivision.

    (b) One hundred and fifty percent of the Medicare fee for service fee schedule for the health care service provided, excluding any in-network coinsurance, copayments, or deductibles.

    (6) A nonemergency patient’s carrier shall pay the amount described in subsection (5) to the nonparticipating provider within 60 days after receiving the claim from the nonparticipating provider under subsection (5). The nonparticipating provider shall not collect or attempt to collect from the nonemergency patient any amount other than the applicable in-network coinsurance, copayment, or deductible.