Renown Policy v2021 Page 9 of 9
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. I ALSO AUTHORIZE RENOWN HEALTH TO OBTAIN INFORMATION NECESSARY FOR VERIFICATION OF MY FINANCIAL POSITION.
SIGNATURE OF RESPONSIBLE PARTY
Date
Following a determination of FAP eligibility, a FAP-eligible individual may not be charged more than the AGB for emergency or other medical necessary care. As of 9 / 01 / 2022 the AGB is 26 % of charges. For information on how the AGB is calculated please contact us at 775-982-5747.