(a) In addition to the notice required under § 254.155, a facility shall provide to a patient or a patient’s legally authorized representative a written disclosure statement in accordance with this section that:
(1) lists the facility’s observation and facility fees that may result from the patient’s visit; and
(2) lists the health benefit plans in which the facility is a network provider in the health benefit plan’s provider network or states that the facility is an out-of-network provider for all health benefit plans.
(b) A facility shall provide the disclosure statement in accordance with the standards prescribed by § 254.153(a).

(c) The disclosure statement must be:
(1) printed in at least 16-point boldface type;
(2) in a contrasting color using a font that is easily readable; and
(3) in English and Spanish.
(d) The disclosure statement:
(1) must include:
(A) the name and contact information of the facility; and
(B) a place for the patient or the patient’s legally authorized representative and an employee of the facility to sign and date the disclosure statement;
(2) may include information on the facility’s procedures for seeking reimbursement from the patient’s health benefit plan; and
(3) must, as applicable:
(A) state “This facility charges a facility fee for medical treatment” and include:
(i) the facility’s median facility fee;
(ii) a range of possible facility fees; and
(iii) the facility fees for each level of care provided at the facility; and
(B) state “This facility charges an observation fee for medical treatment” and include:
(i) the facility’s median observation fee;
(ii) a range of possible observation fees; and
(iii) the observation fees for each level of care provided at the facility.
(e) A facility may include only the information described by Subsection (d) in the required disclosure statement and may not include any additional information in the statement. The facility annually shall update the statement.
(f) A facility shall provide each patient with a physical copy of the disclosure statement even if the patient refuses or is unable to sign the statement. If a patient refuses or is unable to sign the statement, as required by this section, the facility shall indicate in the patient’s file that the patient failed to sign.
(g) A facility shall retain a copy of a signed disclosure statement provided under this section until the first anniversary of the date on which the disclosure was signed.
(h) A facility is not required to provide notice to a patient or a patient’s legally authorized representative under this section if the facility determines before providing emergency health care services to the patient that the patient will not be billed for the services.
(i) A facility complies with the requirements of Subsections (a)(1) and (d)(3) if the facility posts on the facility’s Internet website in a manner that is easily accessible and readable:
(1) the facility’s standard charges, including the fees described by those subsections; and
(2) updates to the standard charges at least annually or more frequently as appropriate to reflect the facility’s current charges.
(j) A facility’s failure to obtain the signed disclosure statement required by this section from the patient or the patient’s legally authorized representative may not be a determining factor in the adjudication of liability for health care services provided to the patient at the facility.