Upon arrival for your procedure, you will be asked to read and sign the following “Authorization and Acknowledgements”
1. AUTHORIZATION FOR TREATMENT: The undersigned requests outpatient treatment at and/or admission to High Point Surgery Center and gives permission to the physicians in charge of the patient’s care to administer treatment deemed necessary or advisable related to the diagnosis and treatment of the patient. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made as to the results of treatment or examination at High Point Surgery Center.
2. RELEASE OF INFORMATION: I authorize High Point Surgery Center to disclose all or any parts of the patient’s medical record including, but not limited to, records pertaining to the treatment of psychiatric or drug and alcohol abuse conditions, and/or information concerning AIDS, AIDS related conditions, or HIV status for the purpose of review and payment of all High Point Surgery Center or physician bills. The parties who may receive this information may include, but are not limited to, insurance companies, government agencies, employer of patient or guarantor providing insurance coverage or any agency conducting reviews concerning Workers Compensation and any review agency which conducts reviews of surgery center utilization under an agreement with the employer of the patient or guarantor providing insurance coverage or other payment source. Medical information including, but not limited to, records pertaining to the treatment of psychiatric or drug and alcohol abuse conditions, and/or information concerning AIDS, AIDS related conditions, or HIV status, may be disclosed to any physician, health care organization or agency needing medical information to assist in the patient’s continuing care, or for research purposes with the understanding that the confidentiality of the information will be maintained. The patient/guarantor understands that he/she may revoke this authorization at any time by providing written notice to High Point Surgery Center.
3. MEDICARE-MEDICAID PATIENT CERTIFICATION: I certify that the information given by me in applying for payment under Title XVIII and/or XIX of the Social Security Act is correct. I request that payment of authorized benefits be made on the patient’s behalf directly to High Point Surgery Center. As an outpatient, I understand that Medicare will not cover or pay for medications that are self-administered and I agree to pay for these medications. I understand that if the patient is a member of Carolina Access (Medicaid Managed Care) and if the patient receives non-emergent treatment not covered or paid for by Medicaid, I will be responsible for any and all charges associated with those medical services and agree to pay for said non-emergent treatment and care.
4. ASSIGNMENT OF INSURANCE/LIABILITY BENEFITS: I authorize and direct all insurers to pay directly to High Point Surgery Center any and all benefits up to the amount of the patient’s bill pertaining to all charges from preadmission through discharge. I authorize and direct all insurers to pay directly to High Point Surgery Center any medical, surgical and liability benefits otherwise payable to the patient. In the event that payment is received from more than one source, causing overpayment for this treatment at High Point Surgery Center, I authorize application of the overpayment to any unpaid High Point Surgery Center bill for which I would be legally responsible that has not been paid in full at the time of the receipt of the overpayment.
5. PROMISE TO PAY ACCOUNT: For and in consideration of services rendered and to be rendered by High Point Surgery Center, I promise to pay all charges incurred for the patient account from preadmission to discharge. I understand that I will be responsible for any and all charges not deemed as covered items/services by any payor, including but not limited to Medicare, Medicaid, any indigent care program or any other Federal, State or County regulated agency. I understand that I am financially responsible to High Point Surgery Center for all charges not covered by liability insurance. In the event that I default in the obligation of payment to High Point Surgery Center and it becomes necessary for High Point Surgery Center to place the account in the hands of any attorney for collection, I agree to pay reasonable attorneys’ fees of fifteen percent (15%) of the balance due and all costs and other expenses incurred in the collection of this account.
6. DETAILED STATEMENT OF CHARGES: Available Upon Request.
7. PHYSICIAN AND IMPLANT BILLING: I understand that all physicians furnishing services to the patient (for example, surgeons, radiologists, pathologists and anesthesiologists) are not employees or agents of High Point Surgery Center. I understand that each physicians will bill the patient separately for the services he/she provides to the patient at High Point Surgery Center. I understand that for certain insurance companies, implants will be billed by a third party implant provider for implants provided to the patient at High Point Surgery Center.
8. PERSONAL VALUABLES: I release High Point Surgery Center from any responsibility for valuables, money, personal or other possessions, which are not given to and accepted by High Point Surgery Center for safekeeping.
9. NOTICE OF PRIVACY PRACTICES: I understand that I may receive the Notice of Privacy Practices of High Point Regional (High Point Surgery Center) by going to the website http://www.highpointsurgerycenter.com/privacy2.html.
10. REQUIRED FEDERAL INFORMATION: I acknowledge that, prior to surgery, I have received written and verbal information about the following:
- Patient Rights and Responsibilities at High Point Surgery Center
- Advance Directives
- Disclosure Of Physician Ownership in High Point Surgery Center