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Hospital/Facility Hospital
All 50 32060

MADISON COUNTY MEMORIAL 224 NW CRANE AVE 21.28 miles Essential Community Provider
HOSPITAL Madison Florida, 32340
Hospital (850) 973-2271
Accepts Medicaid

HCA FLORIDA LAKE CITY HOSPITAL 340 NW Commerce Drive 27.28 miles
Hospital Lake City Florida, 32055
Accepts Medicaid (386) 719-9000

DOCTORS MEMORIAL HOSPITAL - 333 N BYRON BUTLER PARKWAY 30.68 miles Essential Community Provider
PERRY Perry Florida, 32347
Hospital (850) 584-0800
Accepts Medicaid

Provider information contained in this directory is refreshed nightly with the exception of Pharmacy (refreshed monthly). Blue Cross and Blue Shield Licensees have made reasonable efforts to validate that the
information displayed is up to date and accurate. Please call the provider prior to scheduling an appointment to verify that the provider continues to be part of the network. Neither the Blue Cross and Blue Shield
Association nor any of its Licensees shall be liable for any losses, damages, or uncovered charges as a result of using this provider locator website or receiving care from a provider listed in this website.

Created as of 11/21/2023 1 of 4
 Section 1557 Notification: Discrimination is Against the Law
We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude
people or treat them differently because of race, color, national origin, age, disability, or sex.

We provide:
Free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provide free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages

If you need these services, contact:

Health and vision coverage: 1-800-352-2583
Dental, life, and disability coverage: 1-888-223-4892
Federal Employee Program: 1-800-333-2227

If you believe that we have failed to provide these services or discriminate on the basis of race, color, national origin, disability, age, sex, gender identity or sexual
orientation, you can file a grievance with:

Health and vision coverage

(including FEP members): Dental, life, and disability coverage:
Section 1557 Coordinator Civil Rights Coordinator
4800 Deerwood Campus Parkway, DCC 1-7 17500 Chenal Parkway
Jacksonville, FL 32246 Little Rock, AR 72223
1-800-477-3736 x29070 1-800-260-0331
1-800-955-8770 (TTY) 1-800-955-8770 (TTY)
Fax: 1-904-301-1580 civilrightscoordinator@fclife.com
section1557coordinator@floridablue.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you. You can also
file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights
Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019
1-800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-352-2583 (TTY: 1-877-955-8773). FEP: Llame al
1-800-333-2227
ATANSYON: Si w pale Kreyòl ayisyen, ou ka resevwa yon èd gratis nan lang pa w. Rele 1-800-352-2583 (pou moun ki pa tande byen: 1-800-955-8770). FEP:
Rele 1-800-333-2227
CHÚ Ý: Nếu bạn nói Tiếng Việt, có dịch vụ trợ giúp ngôn ngữ miễn phí dành cho bạn. Hãy gọi số 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Gọi số 1-800-333-
2227
ATENÇÃO: Se você fala português, utilize os serviços linguísticos gratuitos disponíveis. Ligue para 1-800-352-2583 (TTY: 1-800-955-8770). FEP: Ligue para 1-
800-333-2227
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-800-352-2583（TTY: 1-800-955-8770)。FEP：請致電1-800-333-2227
ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-352-2583 (ATS : 1-800-955-8770). FEP
: Appelez le 1-800-333-2227
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-800-352-2583 (TTY:
1-800-955-8770). FEP: Tumawag sa 1-800-333-2227
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-800-352-2583 (телетайп: 1-800-955-8770).
FEP: Звоните 1-800-333-2227
‫ةظوحلم‬: ‫ةغللا ركذا ثدحتت تنك اذإ‬، ‫ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف‬. ‫ مقرب لصتا‬1 - 3852-253-008 )‫مكبلاو مصلا فتاه مقر‬: 1 - 0778-
559-008 . ‫ مقرب لصتا‬1 - 008 - 333 - 7222
ATTENZIONE: Qualora fosse l'italiano la lingua parlata, sono disponibili dei servizi di assistenza linguistica gratuiti. Chiamare il numero 1-800-352-2583 (TTY: 1-
800-955-8770). FEP: chiamare il numero 1-800-333-2227
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: +1-800-352-2583 (TTY: +1-800-
955-8770). FEP: Rufnummer +1-800-333-2227
주의: 한국어 사용을 원하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-352-2583 (TTY: 1-800-955-8770) 로 전화하십시오. FEP: 1-800-333-
2227 로 연락하십시오.
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-800-352-2583 (TTY: 1-800-955-8770). FEP:
Zadzwoń pod numer 1-800-333-2227.
સુચના: જો તમે ગુજરાતી બોલતા હો, તો નન:શુલ્ક ભાષા સહાય સેવા તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-800-352-2583 (TTY: 1-800-955-8770). FEP: ફોન કરો 1-800-333-2227
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-352-2583（TTY: 1-800-955-8770）まで、お電話にてご連絡ください。FEP:
1-800-333-2227
注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-800-352-2583（TTY: 1-800-955-8770）まで、お電話にてご連絡ください。FEP:
1-800-333-2227
‫هجوت‬: ‫دینک یم تبحص یسراف نابز هب رگا‬، ‫دوب دهاوخ امش سرتسد رد ناگیار ینابز تالیهست‬. ‫ هرامش اب‬1-800-352-2583 (TTY: 1-800-955-8770) ‫سامت‬
‫ديریگب‬. FEP : ‫ هرامش اب‬1-800-333-2227 ‫ديریگب سامت‬.
Baa ákonínzin: Diné bizaad bee yáníłti’go, saad bee áká anáwo’, t’áá jíík’eh, ná hólǫ́. Kojį’ hodíílnih 1-800-352-2583 (TTY: 1-800-955-8770). FEP ígíí éí kojį’
hodíílnih 1-800-333-2227.

Created as of 11/21/2023 2 of 4
 Transparency in Coverage Notice
[date of notice]

You’re receiving this notice because you requested a cost estimate for an item or service. This notice contains important information about the cost estimate and
information on the amount you may be required to pay for this item or service.

Definition of terms
Allowed amount:The maximum amount your plan pays for Covered Services.
Amount billed: Amount billed by the provider of services.
Amount paid: Amount paid to you or the provider for Covered Services, including any interest for claims that were not paid on
time.
Coinsurance:: The percentage (%) you may pay for services after you meet any appliable deductible.
Copayment: For some health care services you’ll pay a flat fee, usually at the time you receive the care.
Deductible: The dollar amount you must pay each year before insurance begins to pay for certain health care services. You pay
the plan deductibles first, then copay and/or coinsurance (%) may apply.
Description of service: Procedure, service or supply provided, billed, and processed.
Diagnosis codes: Numerical codes a provider uses to identify specific health conditions during the procedure or date of service.
Procedure codes: Numerical codes used to identify specific health procedures or treatments performed by a provider.
Provider: Doctor, hospital, facility, supplier, or person that bills for health care services.
Prior coverage authorization/pre-service notification programs
Your health plan may perform a pre-service review before it will cover this item or service. This is called prior coverage
authorization. Your health plan may impose additional costs if you or your provider do not submit this item or service for prior
coverage authorization before the item or service is provided.
Preventive services
For items and services that are recommended preventive services under section 2713 of the Public Health Service Act, an in-
network item or service may not be subject to cost-sharing if it is billed as a preventive service. An annual wellness visit is an
example of a preventive service.
3rd Party Payor
Copayment assistance and other third-party payments are not applied to your Out-of-Pocket Max or Deductible; therefore, if you
use a discount or coupon or get support from another organization for your cost sharing, it may not accumulate to your Out-of-
Pocket Max or Deductible balances.
Get in touch
For questions about this Advance Explanation of Benefits (EOB), please call 1-877-352-2583 or write to us at the address listed
on the top of the first page of this statement. You may request or we will provide the diagnosis and treatment codes, as well as
their corresponding meanings, applicable to this notice.
This is just an estimate
The actual charge for the item or service may be different than the cost estimate, depending on the actual care you receive.
Please note that all cost estimates provided have been rounded to the nearest dollar.
For example, if your physician provides additional services during your visit, your charges could be more than the cost estimate.
This is one reason why it is important to discuss with your provider both before and during your visit which items and services you
will receive and to request a new cost estimate if new information becomes available.
This cost estimate is not a benefit determination or guarantee of coverage for the item or service for which you requested
information. For example, your plan may need to determine whether the item or service is medically necessary in your case
before making a payment. You should follow your health plan’s process for filing a claim for benefits and contact your health plan
to help determine if there are any additional requirements that apply to you as part of the process.
Your protections against surprise billing
When you see a doctor or other health care provider, you may owe certain out-of-pocket-costs, like a copayment, coinsurance, or
deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t
in your health plan’s network.
“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-
network providers may be allowed to bill you for the difference between what your plan pays, and the full amount charged for a
service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count
toward your plans’ deductible or annual out-of-pocket limit.
“Surprise billing” is an unexpected bill. This can happen when you can’t control who is involved in your care—like when you have
an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
Surprise medical bills could cost thousands of dollars depending on the procedure or service.
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most they
can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be
balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give
written consent and give up your protections not to be balanced billed for these post-stabilization services.
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network.
In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency
medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services.
Reminder
You are never required to give up your protections from “surprise billing.” You are not required to get Out-of-Network care. You
can choose a provider or facility that is in your plan’s network.
Florida Blue and Florida Blue HMO are Independent Licensees of the Blue Cross and Blue Shield Association. We comply with
Created as of 11/21/2023 3 of 4
 applicable Federal civil rights laws and do not discriminate. You may access the Nondiscrimination and Accessibility notice at
floridablue.com/ndnotice.
4800 Deerwood Campus Pkwy, Jacksonville, FL 32246.
Español, Kreyol, Ayisien

Created as of 11/21/2023 4 of 4