UNDERSTAND YOUR CHARGES WE VALUE YOUR OPINION › wp-content › uploads › SC... · Todd Hobgood, MD Lisa Mansueto, MD Bertram Matsumoto, MD Nathan Page, MD Jeff Pawlowski, DPM

Patient Guide & Information

Accredited by Accreditation Association for Ambulatory Health CareLicensed by the state of Arizona and Medicare certified

Surgery Date: ______________________________________________

Time of Surgery: ____________________________________________

Time to Arrive at the Center: ___________________________________

Surgeon: __________________________________________________

Special Instructions: _________________________________________

__________________________________________________________

__________________________________________________________

The Surgery Center of Gilbert always strives for excellence. We value each patient’s opinion regarding our services. If you have comments or concerns feel free to contact

our Administrator at 480-641-6500. A patient satisfaction survey will be given to you during your stay.

Please help us by sharing your surgery center experience. Your opinion is valuable to our future excellence.

YOUR INSURANCEAs a courtesy to our patients, we will bill your insurance company when provided with the necessary information. Please realize that your policy is a contract between you and the insurance company. We are not a party to that contract. Any required co-payments, deductibles or non-covered services are beyond our control, and are your responsibility.The Surgery Center of Gilbert accepts payment from all insurance companies. Your insurance company may or may not pay all charges. Contact your employer or insurance company if you have questions about your coverage. You may contact our business office with questions regarding our fees, the level of benefits provided from your insurance and your subsequent responsibility.PATIENT STATEMENTSAll charges are your responsibility from the date services are rendered. After your insurance has remitted payment to us, you may be responsible for any balance unpaid by your insurance company. For your convenience, we accept cash, personal checks, debit and credit cards through MasterCard, Visa, American Express and Discover. We strongly encourage you to contact us to discuss your healthcare benefits and any financial responsibility you may have prior to your procedure, so that you can concentrate on your recovery.

TYPES OF BILLSBelow is a brief explanation of the possible charges which you may receive following a surgery:

Surgery CenterThis fee is for the Center, staff and equipment we provide for your safe and successful experience. Questions regarding your surgery center billing should be addressed to our business office.

PhysicianYour procedure will be performed by a surgeon. Since this physician is not an employee of our Center, he/she will bill you separately for your procedure. Any questions pertaining to the physician bill should be directed to their office.

AnesthesiologistIf you receive anesthesia from an anesthesiologist during your procedure, you will receive a separate bill for these services. These physicians are not employees of the Center. You should address all questions and send all payments to the respective billing group or physician.

Other ChargesDepending on several factors related to your particular procedure, you may receive other charges. These may include laboratory fees or other services not performed at the Surgery Center of Gilbert. Questions regarding these charges should be directed to the respective company or provider.

Surgery Center of Gilbert is located on the South side of Baseline, just East of Recker Road.

SURGERY CENTER OF GILBERT6003 E. Baseline Rd. Mesa, Arizona 85206

P 480-641-6500 F 480-641-6550

Open Monday - Friday 6:00 a.m. to 5:00 p.m.

Tobacco Free Campus

Please visit our website, where you may download forms and get additional information.www.gilbert-sc.com

As part of the Conditions of Coverage for Ambulatory Surgical Centers, the Centers for Medicare & Medicaid Services (CMS) requires us to notify you that the following physicians have a minority ownership interest in the Surgery Center of Gilbert:

Charles Connell, DPM Stuart Eason, MDMichael Fucci, MDGavin Gonzalez, MDBarry Gordon, MDDavid Grossklaus, MDGrant Heinz, MD

Todd Hobgood, MDLisa Mansueto, MDBertram Matsumoto, MDNathan Page, MDJeff Pawlowski, DPMRaquel Redtfeldt, MDJames Reidy, DO

Scott Salmon, DO Namir Shaba, DOFrank Simoncini, DOJoseph Worischeck, MDLeopold Yin, MD

Please be advised that you may choose any other organization for the purpose of obtaining the services ordered or requested.

BILLING

UNDERSTAND YOUR CHARGESWE VALUE YOUR OPINION

NOTICE OF OWNERSHIP

E. Guadalupe

E. Baseline Road 6003 E. Baseline Rd.

Pow

er R

oad

Rec

ker R

oad

Gre

enfie

ld R

oad

Hig

ley

Roa

d

US 60

You Have The Right ToReceive access to equal medical treatment and accommodations regardless of race, creed, sex, national origin, religion or sources of payment for care.

Be fully informed and have complete information, to the extent known by the physician, regarding diagnosis, treatment, procedure and prognosis, as well as the risks and side effects associated with treatment and procedure prior to the procedure.

Exercise your rights without being subjected to discrimination or reprisal.

Voice grievances regarding treatment or care that is (or fails to be) furnished.

Personal privacy.

Receive care in a safe setting.

Be free from all forms of abuse or harassment.

Receive the care necessary to regain or maintain your maximum state of health and if necessary, cope with death.

Expect personnel who care for you to be friendly, considerate, respectful and qualified through education and experience, as well as perform the services for which they are responsible with the highest quality of service.

Be fully informed of the scope of services available at the Center, provisions for after-hours care and related fees for services rendered.

Be a participant in decisions regarding the intensity and scope of treatment. If you are unable to participate in those decisions, the patient’s rights shall be exercised by your designated representative or other legally designated person.

Make informed decisions regarding your care.

Refuse treatment to the extent permitted by law and be informed of the medical consequences of such refusal. The patient accepts responsibility for his or her actions including refusal of treatment or not following the instructions of the physician or Center.

Approve or refuse the release of medical records to any individual outside the Center, or as required by law or third party payment contract.

Express grievances/complaints and suggestions at any time.

Access to and/or copies of your medical records.

Be informed as to the Center’s policy regarding Advance Directive/Living Will/Power of Attorney.

Be fully informed before any transfer to another Center or organization and ensure the receiving Center has accepted the patient transfer.

Express those spiritual beliefs and cultural practices that do not harm or interfere with the planned course of medical therapy for the patient.

Expect the Center to agree to comply with Federal Civil Rights Laws that assure it will provide interpretation for individuals who are not proficient in English.

Have an assessment and regular assessment of pain.

Education of you and your family, when appropriate, regarding your roles in managing your pain.

To change providers if other qualified providers are available.

If a patient is adjudged incompetent under applicable state health and safety laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under state law to act on the patient’s behalf.

If a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state laws may exercise the patient’s rights to the extent allowed by state law.

So that you may contribute effectively to your health care, you have, as a patient, the following responsibilities:Bring health insurance card.Bring government issued photo identification.Bring form of payment if applicableBe certain to bring documentation of Guardianship or Power of Attorney (POA) if applicable.Be considerate of the rights of other patients and personnel and assist in the control of noise, number of visitors, eating and other distractions.Respect the property of others and the CenterReport whether you clearly understand the planned course of treatment and what is expected of you.Keep appointments and, when unable to do so for any reason, notify the Physician and Center.Provide care givers with the most accurate and complete information regarding present complaints, past illnesses, hospitalizations, and medications. Report unexpected changes in your condition or any other health matters.Observe prescribed rules of the Center during your stay and treatment and, if instructions are not followed, forfeit the right to care at the Center.Promptly fulfill your financial obligations to the Center.Identify any patient safety concerns.

All patients have the right to participate in their own health care decisions and to make advance directives or to execute power of attorney that authorize others to make decisions on their behalf based on the patient’s expressed wishes when the patient is unable to make decisions or unable to communicate decisions. This surgery center respects and upholds those rights.However, unlike in an acute care hospital setting, the surgery center does not routinely perform ‘high risk’ procedures. Most procedures performed in this facility are considered to be of minimal risk. Of course, no surgery is without risk. You will discuss the specifics of your procedure with your physician who can answer your questions as to its risks, and your expected recovery and care after your surgery. Therefore, it is our policy, regardless of the contents of any advance directives or instructions from a health care surrogate or attorney in fact, that if an adverse event occurs during your treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. At the acute care hospital further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, advance directives or health care power of attorney. Your agreement with this policy below does not revoke or invalidate any current health care directive or health care power of attorney. If you do not agree to this policy, we are pleased to assist you to reschedule the procedure.

Arizona Department of Health Services Division of Assurance & Licensure Services

150 N. 18th Avenue, Suite 450, Phoenix, AZ 85007-3245, 602-364-3030OR

State of Arizona, CMS Regional Office DHHS/CMS/DSC/CLIA

90 7th Street, Suite 5-300 (5W), San Francisco, CA 94103-6707, 415-744-3696 OR

Accreditation Association for Ambulatory Health Care, Inc. 5250 Old Orchard Road, Suite 200, Skokie, IL 60077, 847-853-6060

Thank you for choosing the Surgery Center of Gilbert for your outpatient procedure. We are committed to providing you with quality surgical services in a convenient outpatient setting.

Our mission is to provide first-class surgical services for the local community in a safe, comfortable and welcoming environment; one in which we would be happy to treat our own families.

As you read through the brochure, call if you have any questions.

Again, welcome to our Center. We look forward to caring for you.

Surgery Center of Gilbert

WELCOME

BEFORE YOUR SURGERY

YOUR RIGHTS YOUR RESPONSIBILITIES

ADVANCE DIRECTIVES

PLEASE REMEMBER TO BRING:• Health Insurance Card• Government Issued Photo Identification• Form of payment (if applicable)• Guardianship/Power of Attorney (if applicable)• A list of current medications

PHYSICIAN VISIT Your physician will let you know what time you should arrive at the Center on the day of your surgery and give you any specific medical restrictions/recommendations you must follow prior to your surgery.

PRE-OP CALL You may receive a telephone call from a nurse at the Center 1 or 2 days prior to your procedure to discuss your health history.

CHANGE IN CONDITION If you experience any changes such as a cold, fever or rash, please contact your physician prior to your surgery.

RESPONSIBLE PARTY You must be accompanied by a responsible adult to provide transportation home after discharge from the Center and to stay with you for the first 24 hours following your procedure. This individual must be present at the center at all times during your visit. The responsible party for children under 18 must be a parent or guardian.

MIDNIGHT BEFORE SURGERY FOOD No eating or drinking. This includes water, coffee, tea, gum, chewing tobacco,

mints or candy.

MORNING OF SURGERY FOOD Do not eat or drink anything unless otherwise directed. MEDICATIONS Take blood pressure and/or heart medication (if prescribed) with a

small sip of water. Your doctor or pre-op nurse will advise you concerning all other medication.

CLOTHING Wear comfortable, loose-fitting clothes that are easily removed. CONTACT LENSES Bring your glasses with a case. Do not wear contact lenses. VALUABLES Leave all jewelry, valuables and piercings at home.

It is important that you read and understand the information contained in this brochure. You will be asked to acknowledge receipt of this information on your date of service. If you do not acknowledge receipt of information, your surgery may be delayed or cancelled.

Complaints and grievances may also be filed through:

Medicare beneficiaries may receive information regarding their options under Medicareand their rights and protections by visiting the website for the Office of the

Medicare Beneficiary Ombudsman at: http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/

ombudsman.html