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Are you currently living at any of these facilities? If yes, please check one

I give Surgical Associates of the Mid Cities, and/or any of the staff, permission to release any information regarding my medical records to the following persons (Grandparents, Spouse, Adult Children, Caregivers)

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We promise to provide you with the highest quality surgical care combined with empathy and compassion! Surgical Associates of the Mid-Cities, PA

Women Only:

Allergies/Intolerance:

No Drug Allergies

At Surgical Associates of the Mid-Cities, our goal is to provide quality surgical care in a timely manner. We have implemented a no show and cancellation policy which enables us to better utilize available appointments for our patients in need of surgical care. The following policy is with regards to patients who fail to keep their scheduled office visit appointment. Please be courteous and call our office promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment. Available appointments are in high demand and your early cancellation will give another person the possibility to have access to timely surgical care.

 Patients who fail to show for their scheduled appointment or did not notify the office within 24 hours of their scheduled appointment time, shall be subject to a “No Show/Cancellation” fee of $35.00. In the event of an actual emergency and prior notice could not be given, consideration will be given, and a one-time exception may be granted.

 As a courtesy, we make reminder calls for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect.

 These fees are not covered by insurance and is therefore the sole responsibility of the patient.

How to Cancel Your Appointment To cancel or reschedule an appointment call Surgical Associates of the Mid-Cities at 817-267-2678.

SURGICAL ASSOCIATES OF THE MID-CITIES recognizes the need for a clear understanding between patient and surgeon regarding payment for surgical care. The following information is provided to avoid any misunderstanding concerning payment for professional services:

• Payment: If your deductible or out of pocket expense that is your responsibility has not been met, we expect payment when services are rendered. You are exempt from this policy if your primary insurance carrier is Medicare or a managed care insurance that requires only a co-payment at the time of service. EVEN THOUGH INSURANCE WILL BE FILED, YOU ARE RESPONSIBLE FOR ANY BALANCE AFTER INSURANCE PAYMENTS HAVE BEEN MADE. All charges for treatment become due and payable WITHIN ninety (90) days after date of service. This period allows you time to make payment in full of any remaining balance.

• Nurse/Surgical Assistant Fees: Your surgeon may have this nurse, or one of his partners in the operating room, acting as a first assistant. The first assistant’s presence helps your operation proceed in a safe and responsible manner. Your insurance will be billed for the assistant’s service and you may be financially responsible for a portion of the assistant’s charges after the insurance company has paid your allowable.

• Self-payment (private, cash payments): If you have no insurance coverage, we ask that you coordinate your care with our business office prior to your surgery. We require an advance payment for professional services.

• Managed Care: All Managed Care co-payment amounts are due to at the time of service

• Medicare: We are participating providers with the Medicare program and accept as payment. If you have secondary insurance to cover the 20% portion of charges, please provide us with a copy of both insurance cards.

• Children of divorced parents: Responsibility of payment for treatment of minor children, whose parents are divorced, rests with the parent who seeks the treatment. Any court ordered responsibility judgement must be determined between the individual involved, without the inclusion of Surgical Associates of the Mid-Cities.

• IT IS YOUR RESPONSIBILITY TO ENSURE THAT THE PHYSICIAN YOU ARE SEEING IS PART YOUR INSURANCE NETWORK. It is also required that you OBTAIN AND HAVE AT THE TIME OF YOUR VISIT ANY REFERRAL REQUIERED BY YOUR PLAN. Failure to obtain this referral may deem your medical treatment as “Out of Network” by your insurance company and you will be responsible for a larger amount of the charges. We will obtain pre-certifications required for your office procedure and surgeries.

• Collections: I understand that I am financially and legally responsible for all charges. I further agree that should I not pay the balance within ninety (90) days after date of service my account will be turned over for collections and will be responsible for all costs, collection agency fees and interest, which shall accrue at the maximum rate allowed by law.

• General Consent for Treatment: I consent to and authorize Surgical Associates of the Mid-Cities to treat any condition that I might have and seek to have treated.

(If patient is a minor under 18 years of age)

This Notice of Privacy Practices below details how your information can/may be used. We at Surgical Associates of the Mid-Cities honor the privacy of your health information and yield these terms. You understand that under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), you have certain rights to privacy regarding your protected health information. You understand that this information can and will be used to:

• Conduct, plan, and direct your treatment and follow-up among the multiple healthcare providers who may be involved in that treatment

• Obtain payment from third-party payers such as insurance, verify eligibility and benefits, billing and/or collections

• Conduct normal healthcare operations such as quality assessments and physician certifications to help SAMC provide you with the utmost quality care Surgical Associates of the Mid-Cities will not disclose any health information without your permission. You as a patient at Surgical Associates of the Mid-Cities have the right to:

• Request restrictions on uses and disclosures

• Receive confidential communication regarding your protected health information

• Inspect and copy your protected health information

• Change or modify your protected health information as you see fit You acknowledge that you have received your Notice of Privacy Practices of the uses and disclosures of your health information. You understand that Surgical Associates of the Mid-Cities has the right to change its notice of Privacy Practices at any time, and that you may contact this organization to obtain a current copy of the Notice of Privacy Practices. You understand that you may request in writing that you restrict how your private information is used or disclosed to carry out treatment, payment, or health care operations.