Patient Registration

The above information, including patient, insurance, and coordination of benefits information, is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Laredo Emergency Room, Laredo Doctors Healthcare, LLC and LER Radiology, LLC. I understand that I am financially responsible for any balance. I also authorize Laredo Emergency Room, Laredo Doctors Healthcare, LLC and LER Radiology, LLC or the insurance company to release any information required to process my claims. In addition to the terms and policies stated herein, I agree to the terms, policies, and conditions set forth in Laredo Emergency Room's Consents and Terms.

I understand that this Authorization, and all other authorizations herein, are being executed through the use of an electronic signature in accordance with the Electronic Signatures in Global and National Commerce Act (E-Sign Act), Title 15, U.S.C. § 7001 et seq., the Uniform Electronic Transaction Act (UETA), and any applicable state law, and that any electronic signature shall be deemed an original signature for the purposes of this Authorization, with such electronic signature having the same legal effect as an original signature.

I understand that I am checking into a freestanding emergency room, and that this is not an urgent care center.

Dear Medicare/Medicaid Beneficiary:

Because the Centers for Medicare and Medicaid Services (a federal agency) does not yet recognize free‐standing emergency departments such as Laredo Emergency Room, we cannot accept Medicare or Medicaid as a form of insurance.

However, since your health is our number one priority, we offer medical screening examinations to all patients. If you are found to have an emergent medical condition, we will treat you regardless of the ability to pay at the time of service, and you will be billed as applicable for services rendered.

For those who do not have an emergent medical condition, we still offer discounted self‐pay rates if you elect to pay the same day of service. However, you will not be able to submit claims for reimbursement to Medicare or Medicaid for facility services rendered by Laredo Emergency Room.

By signing below, I acknowledge that I have read and understand the information given to me in the above notice.

Disclosure Statement Required: (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 states:

1. This facility charges a facility fee for medical treatment. The average facility fee for patient treatment is $5,000.
2. This facility charges an observation fee for medical treatment. The average observation fee for patient treatment is $13,000.

Included below is a direct link on our website where you may view all of our facility's listed prices:

https://www.laredoemergency.com/fee-schedule

If you have any questions, you may contact us using any of the methods below:

Email: info@laredoemergency.com
Phone: +1 (956) 242-6790
Address: 7510 McPherson Rd., Laredo, TX 78041

By signing below, I acknowledge that I have read and understand the information given to me in the above notice.