Disclaimers & Disclosures

Good Faith Estimate

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The
estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute
(appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
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You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith
Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.

“I love how simple the online interface is to get all the basic things done.”

Kelly Brimbore, Newcastle

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other 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” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay 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 annual out-of-pocket limit.

“Surprise billing” is an unexpected balance 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.

You are protected from balance billing for:

Emergency services If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). 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.

In accordance with the Nebraska Out-Of-Network Emergency Medical Care Act, if you receive emergency services from any health care providers, such providers are not permitted to bill you in excess of any deductible, copayment, or coinsurance amount applicable to in-network providers’ emergency services pursuant to your health benefits plan. Your insurer is obligated to make sure that you do not incur out-of-pocket costs greater than the out-of-pocket costs you would have incurred had you received emergency services from an in-network health care provider.

Certain services at an in-network hospital or ambulatory surgical center 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 may 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. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.

If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

The Nebraska Out-Of-Network Emergency Medical Care Act applies only to emergency services. Therefore, as applicable, the billing of your care involving non-emergency services is governed by federal law such as the rights and protections involving non-emergency services discussed in this notice.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.

Your health plan generally must:

- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
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- Cover emergency services by out-of-network providers.
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- Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
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- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact the Department of Health and Human Services (HHS) at 1-800-985-3059.

Visit https://www.cms.gov/nosurprises website for more information about your rights under federal law.

If you have insurance-related questions, please contact the Nebraska Department of Insurance at 402-471-2201 or call toll-free consumer hotline at 1-877-564-7323. Visit www.doi.nebraska.gov for more information about your rights under Nebraska law.

“I love how simple the online interface is to get all the basic things done.”

Kelly Brimbore, Newcastle

Facebook Contest Rules

1. Eligibility: The AMI BBQ Memorial Day giveaway is open to all legal residents of the United States who enter on Facebook. The winner must be able to come to Advanced Medical Imaging, 7601 Pioneers Blvd, Lincoln Nebraska to claim their prize. Entrants must be 16 years of age as of their date of entry in this promotion in order to qualify. This giveaway is subject to federal, state, and local laws and regulations and void where prohibited by law. Advanced Medical Imaging’s employees, its subsidiaries, affiliates, suppliers, partners, advertising and promotion agencies, and directors (collectively the “Employees”), as well as those living in the same household of Employees are ineligible to participate in the giveaway.

2. Sponsorship. The Sponsor is Advanced Medical Imaging, located at 7601 Pioneers Blvd, Lincoln, Nebraska. Sponsor will conduct the giveaway substantially as described in these Official Rules.

3. Agreement to Rules: By entering this giveaway, the Entrants agree to abide by the Sponsor’s Official Rules and decisions, which are fully and unconditionally binding in all respects. The Sponsor reserves the right to refuse, withdraw, or disqualify any entry at any time at the Sponsor’s sole discretion. By entering this giveaway the You represents and warrants that You are eligible to participate based on eligibility requirements explained in the Official Rules. You also agree to
accept the decisions of the Sponsor as final and binding as it relates to the content of this giveaway.

4. AMI BBQ Memorial Day giveaway Entry Period: This promotion begins on 5-20-2022 at 330 pm CST and ends on 5-20-2022 at 3 pm CST. To be eligible for the giveaway, entries must be received within the specified Entry Period.

5. How to Enter: Eligible entrants can enter AMI BBQ Memorial Day giveaway by liking and commenting on the specified post at https://www.facebook.com/amimaging. As a participant, your entry must fully meet all giveaway requirements, as specified in the Official Rules, in order to be eligible to win the prize. Incomplete entries or those that do not adhere to the Official Rules or specifications will be disqualified at the Sponsor’s sole discretion. Participants may only
enter once.

6. Prizes: The Winner of the AMI BBQ Giveaway for Memorial Day will receive BBQ gril tools and basket. The actual/appraised prize value may differ at the
time the prize is awarded. The prize(s) shall be determined solely by the Sponsor. There shall be no cash or other prize substitution permitted except at the Sponsor’s discretion. The prize is non-transferable. The Winner, upon acceptance of the prize, is solely responsible for all expenses related to the prize, including without limitation any and all local, state, and federal taxes. The Winner shall not transfer assignment of the prize to others nor shall the Winner request the cash equivalent or prize substitution. By accepting the prize, the selected Winner grants permission for the Sponsor to use the Winner’s likeness, entry, and name for
purposes of advertising and trade without further compensation unless prohibited by law.

7. Odds: The total number of eligible entries received determines the odds of winning.

8. Selection and Notification of Winner: The Winner will be selected by a random drawing by the Sponsor. The Sponsor will notify the Winner by Facebook messenger within one day following Winner selection. The Sponsor is not responsible for nor shall have no liability for Winner’s failure to receive notices due to security settings that may cause notifications to be marked as spam or junk email. Nor shall be Sponsor be liable for the Winner’s provision of incorrect or otherwise non-functioning contact information. If the Winner 1) fails to claim the prize within 30 days from the time the award notification was sent, 2) is found ineligible the prize may be forfeited and an alternate Winner will be selected. IF THE WINNER VIOLATES ANY OF THESE OFFICIAL RULES, THE WINNER (AT THE SPONSOR’S SOLE DISCRETION) WILL BE DISQUALIFIED AND ALL PRIVILEGES AS WINNER WILL BE IMMEDIATELY TERMINATED.

9. Rights Granted by You: By submitting an entry (e.g., text, video, photo, etc.) into this giveaway, You understand and agree that the Sponsor, any individual acting on the Sponsor’s behalf, and the licensees successors, and assigns of the Sponsor shall, where permitted by law, have the right to print, publish, broadcast, distribute and use in any media known now or hereafter developed, in perpetuity, worldwide, and without limitation, your submission, name, image and statements about the giveaway for news, publicity, advertising, promotional purposes and public relations without any further notice, review, consent, compensation, or remuneration.

10. Terms & Conditions: In its sole discretion, the Sponsor reserves the right to modify, suspend, cancel, or terminate the giveaway should non-authorized human intervention, a bug or virus, fraud, or other causes beyond the Sponsor’s control, impact or corrupt the security, fairness, proper conduct, or administration of the giveaway. The Sponsor, in the event of any of the above issues, may determine the Winner based on all eligible entries received prior to and/or after (if
appropriate) the action taken by the Sponsor. Individuals who tamper with or attempt to tamper with the operation or entry process of the giveaway or website or violates these Terms & Conditions will be disqualified by the Sponsor in its sole discretion. In its sole discretion, the Sponsor has the right to maintain the integrity of the giveaway, to void votes for any reason, including, but not limited to: multiple entries from the same user; or the use of bots, macros, scripts, or
other technical means for entering. Attempts by any entrant to deliberately damage any website or undermine the legitimate operation of the giveaway may be a violation of criminal and civil laws. If any such attempt is made, the Sponsor reserves the right to seek damages to the fullest extent permitted by law.

12. Disputes: THIS GIVEAWAY IS GOVERNED BY THE LAWS OF THE UNITED STATES AND NEBRASKA, WITHOUT RESPECT TO CONFLICT OF LAW DOCTRINES. The Entrant agrees, as a condition of participating in this promotion, that if any disputes cannot be resolved between the Entrant and the Sponsor, and if causes of action arise out of or are connected with this giveaway, they shall be individually resolved exclusively before a court located in Nebraska having
jurisdiction, without resorting to any form of class action. Under no circumstances in any such dispute shall the participant be permitted to obtain awards for, and hereby waives all rights to, punitive, incidental, or consequential damages, including reasonable attorney’s fees, other than participant’s actual out-of-pocket expenses (i.e. costs associated with entering this giveaway). The participant waives all rights to have damages multiplied or increased.

15. The giveaway hosted by Advanced Medical Imaging is in no way sponsored, endorsed, administered by, or associated with Facebook.

“I love how simple the online interface is to get all the basic things done.”

Kelly Brimbore, Newcastle

Duo Authorization (Private)

Disclaimers & Disclosures

Good Faith Estimate

Your Rights and Protections Against Surprise Medical Bills

Facebook Contest Rules

How Can We Assist?

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