From the perspective of the Plan holder/Patient/Beneficiary/Legal Guardian: I have been advised that the Physician (Dr. Karan Johar, MD ; Park Avenue Medicine & Surgery ; KARAN JOHAR MD PLLC dba NYC PAIN SPECIALISTS ; LENOX HILL PAIN MANAGEMENT AND SPINE PLLC, Any Affiliated Providers under these practices is a non—participating provider of your insurance.
I, understand that my health plan may have a network of care providers. I was given this consent form because I wish to involve a care a provider that is not in my insurance plan network. This means I may have to pay more out-of-pocket costs for the referred by my in-network provider and that I have opted for these services, if I have out-of-network benefits, or the entire cost for the referred or opted service, if I don’t have out-of-network benefits.
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