e for any charges if any of the foovnag apply • My health plan requires prior referral by a Pnmary Care Physician (PCP) before recaving services at NYU School of Medicine and I have not obtained such a referral or I receive services in excess of the referral. ancitor • My health plan *stemmas that the se

In bean pros ded a copy of the NYU School of Molione Synod policies and agree to the eroded bre thereof agree to pay al °woe du (ot to become an) to NYU School of lamk:Me ice care and tnealthert Marc co-payments and CleilattiMes es provided uncle( my peen Safes R ers, pod by. thed patty, creditol do loccul

any charges if any of the following apply: • My health plan requires prior referral by a Primary Care Physician (PCP) before receiving services at NYU School of Medicine and I have not obtained such a referral or I receive services in excess of the referral, and/or • My health plan determines that the s