ACKNOWLEDGEMENT

I understand this is only a list of standard charges for services and products provided by Harney District Hospital. This does not include charges related to professional services provided and billed separately by providers within or outside of Harney District Hospital. I also understand this is only a list of charges, and the amount listed may not ultimately be my responsibility to pay for out-of-pocket as there are many other factors that lead to what determines this, such as insurance coverage, financial assistance, self-pay discount, etc.