Notice and Disclosure Statement to All Patients

• This facility is a licensed Freestanding Emergency Medical Care Facility.
• This facility charges rates comparable to a hospital emergency room and charges a facility fee. The median facility fee and range of possible facility or fees for each level of care provided at our respective facilities are provided below in the applicable charge master.
• This facility charges an observation fee for medical treatment requiring observation services.   The median observation fee for each level of care provided at our respective facilities are provided below in the applicable charge master.
• The facility or physician providing medical care at the facility may be an out-of-network provider for the patient’s health benefit plan provider network.
• The physician providing medical care at this facility may bill separately from the facility for the medical care provided to a patient.
• This facility is an out-of-network provider for all health benefit plans.

If you have questions, call an Ally Medical Emergency Room Patient Advocate at 512-234-1081.