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The purpose of this document is to let you know about your protections from unexpected medical bills To use this document properly, the provider or facility should review and complete it in a manner consistent with applicable state and federal law. 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.

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See here for information about potential surprise billing and other protections under connecticut law, and here for information from connecticut regarding federal protections. Health care providers and facilities may, but aren’t required to, use this model notice to meet these disclosure requirements What is “balance billing” (sometimes called “surprise billing”)