Patient Rights and Responsibilities
- You have the right to request restrictions on certain uses and disclosures of your health information. The Surgical Center of The Treasure Coast, LLC is not required to agree to the restriction that you requested. We will notify you if we deny your request to a restriction.
- You have the right to receive your health information through a reasonable alternative means or at an alternative location. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled.
- You have the right to inspect and copy your health information. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in anticipation of a civil, criminal, or administrative action or proceeding.
- You have a right to request that The Surgical Center of The Treasure Coast, LLC amend your health information that is incorrect or incomplete. Weston Outpatient Surgery Center is not required to change your health information and will provide you with information about our denial and how you can disagree with the denial.
- You have a right to receive an accounting of disclosures of your health information made by The Surgical Center of the Treasure Coast, LLC, except that we do not have to account for the disclosures described in parts 1 (treatment), 2 (payment), 3 (Operations), 4 (other uses and disclosures), information provided to you, and 15 (certain government functions) of section I of this Notice of Privacy Practices.
- You have a right to a paper copy of this Notice of Privacy Practices.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Privacy Officer at The Surgical Center of the Treasure Coast, LLC.
Filing a complaint
- If you have a complaint against a hospital or ambulatory surgical center, call the Consumer Assistance Unit Health facility complaint hot line at (850)487-3183 or (888)419-3456 or write to the Agency for Health Care Administration, Consumer Assistance Unit, 2727 Mahan Drive, Tallahassee, FL 32310.
- If you have a complaint against a physician, call the Medical Quality Assurance, Consumer Services office at (850)414-7209 or write to Agency for Health Care Administration, Medical Quality Assurance Consumer Services, 2727 Mahan Drive, Tallahassee, FL 32310. Call toll free at (888)419-3456 to check the status of complaints.
- All Medicare beneficiaries may file a complaint or grievance with the Medicare Beneficiary Ombudsman. Visit the Ombudsman’s webpage at: www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html
Living Wills and Advance Directives
Notice of Policy Regarding Advance Directives
This Facility requires the Policy Regarding Advance Directives notice be signed by each patient prior to scheduled procedure in order to be in compliance with the Self-Determination Act (PSDA) and State law and rules regarding advance directives. Advance directives are statements that indicate the type of medical treatment wanted or not wanted in the event an individual is unable to make those determinations and who is authorized to make those decisions. The advance directives are made and witnessed prior to serious illness or injury.
There are many types of advance directives, but the two most common forms are:
These generally state the type of medical care an individual wants or does not want if he/she becomes unable to make his/her own decisions.
Durable Power of Attorney for Health Care
This is a signed, dated, and witnessed paper naming another person as an individual’s agent or proxy to make medical decisions for that individual if he/she should become unable to make his/her own decisions.
In the ambulatory care setting, if a patient should suffer a cardiac or respiratory arrest or other life-threatening situation, the signed consent implies consent for resuscitation and transfer to higher level of care. Therefore, in accordance with federal and state law, the facility is notifying you it will not honor previously signed advance directives for any patient. If you disagree, you must address this issue with your physician or anesthesiologist prior to signing this form.
FINANCIAL AGREEMENT/OFFICE POLICIES
CO-PAYMENTS AND BALANCES:
Co-payments are due at the time of check in, unless prior arrangements have been made with our Billing Department. This arrangement is part of your contract with your insurance company. If you cannot pay your co-payment, you may have to reschedule your surgery. Unpaid deductibles, co-insurance percentages, non-covered services and/or other outstanding balances are due upon check-in.
INSURANCE CANCELLED OR LAPSED OF COVERAGE:
If insurance cancels for any reason prior to or retroactive of date of surgery you will accept full responsibility for payment in full for commercial rate, benefits of the reduced contracted rate with insurance carriers will not be extended to you. Payment in full for services rendered is due within 30 days unless a written agreement with the business manager is agreed upon and signed. If payment is not made in full within 30 days, your account will be sent to collections.
ASSIGNMENT OF INSURANCE BENEFITS:
I hereby authorize release of information necessary to file a claim with my insurance company, and I assign benefits, otherwise payable to me, to the doctor or group indicated on the claim. I understand that I am financially responsible for any balance not covered by insurance. A copy of my signature is as valid as the original.
GUARANTEE OF ACCOUNT:
This is to certify that I, the undersigned, promise to be responsible for the payment of all charges for services rendered to the named patient. I further understand that all applicable charges are due at the time services are rendered excluding charges that my insurance company is contractually responsible for payment. If this account should require collection procedures, I the undersigned, will be responsible for any charges for services rendered. The undersigned will incur a financial obligation. Your signature below also represents authorization for treatment of the patient receiving services.
Note to Medicaid Patients: The Surgical Center of the Treasure Coast and its physicians DO NOT participate in the Medicaid program. If you are insured through the traditional Medicaid program or Medipass, the person who signs below will be responsible for all charges for services rendered. The undersigned will incur a financial obligation. Your signature below also represents authorization for treatment of the patients receiving services.
CANCELLED OR RETURNED CHECK’S/CREDIT CARD WOULD BECOME IMMEDIATELY DUE WITH ADDITIONAL $25.00 RETURN FEE. PAYMENT DUE IN CASH OR MONEY ORDER.
Estimates and Information
The Surgical Center of the Treasure Coast, LLC (“the Center”) is committed to providing meaningful information to our patients related to financial obligations for healthcare services. The best way for patients to determine their out-of-pocket costs in advance of their visit to Center is to contact their insurance company. However, a patient may request an estimate of anticipated charges for non-emergency care from the Center.
In order for the Center to provide prospective patients with a good faith estimate, your physician’s office must have already scheduled your surgery or procedure with the center. Upon request and as required by Florida Law, the Center will provide to prospective patients an estimate of gross charges, before any adjustment for your healthcare plans or self-pay discounts in writing within seven (7) business days. To request such estimate, please contact our Center at 772-398-9898 or Email us at firstname.lastname@example.org
For More Information, Call (772) 398-9898
GOOD FAITH ESTIMATE FORM
The Surgical Center of the Treasure Coast
|Patient Account Number:|
|Condition Requiring Services:|
|Date of Service:|
|CPT Code||Procedure/Service Booked||Gross Charge|
|Total Estimated Gross Charges Procedures/ Service Booked:|
This is a good faith estimate of The Surgical Center of the Treasure Coast (SCTC) anticipated gross charges for its facility fees charged to pay SCTC for the procedure(s) that have been booked to be done at SCTC by your attending physician to treat your condition (the “Services”). It is being provided pursuant to Florida HB1175. Depending on whether the Services booked are, in fact, the services ultimately rendered to you while a patient of SCTC, the actual gross charges billed for SCTC facility fees may be higher or lower than this estimate.
In accordance with HB1175, SCTC is required to let you know that you may or may not pay less for the Services at another facility or in another health care setting. Please know that your attending doctor who booked your procedure(s) at SCTC may not be on the medical staff of such other facilities or health care setting. Furthermore, your attending physician who booked your procedures to be done at SCTC, and other health care providers, such as anesthesiologists, interoperative monitoring services, durable medical suppliers, and anatomical pathologists, some or all may provide services to you at SCTC, are not a part of SCTC facility fees and, if any other services are provided to you while being a patient of SCTC, the provider(s) will bill separately for their services rendered.
Gross charges are the “retail rates” billed by SCTC, before application of any adjustments for health insurance, health maintenance organization (“HMO”) or self-pay discounts. PLEASE BE ADVISED THAT THIS ESTIMATE HAS NOT AND WILL NOT BE ADJUSTED FOR ANY POTENTIAL SUCH DISCOUNTS. If SCTC believes that you have health insurance and/or HMO coverage(s) that may cover some or all of the services, SCTC may initiate contact with them to determine your cost-sharing responsibilities for SCTC’s bill. You may contact them directly as well for additional information concerning your cost-sharing responsibilities. If SCTC determines that you have cost-sharing responsibilities for SCTC, you will be required to pay your cost-sharing responsibilities in full on or before Services are provided. If you are unable to pay your cost-sharing responsibilities in full on or before Services are provided because you believe you are medically indigent, or you are not covered by an health insurance of HMO, upon request, SCTC, in its sole discretion, may offer you a discount on the amount due and/or offer a payment plan. Any such discount is considered by SCTC to be “charity care”. There is no formal application process for obtaining “charity care” at SCTC. SCTC’s standard collection policy is to produce and send one or more bills to patients for their coast sharing amounts, which if not paid on a timely basis, may then be placed with an attorney or collection to pursue such unpaid amounts. If accounts are placed with an attorney and/or collection agency, the costs charged by the attorney and/or collection agency will be passed onto the patient to pay, and the patients’ credit score may be negatively impacted.
The prices for the procedures listed on this website include the facility fee. The fee listed does not cover the surgeon or the anesthesiologist fees, labs (including pathology), x-rays, physical therapy or rehabilitation.
The price listed may NOT include any hardware or implants necessary for completion of the procedure (plates and screws, e.g. for orthopedic procedures). Estimated price information will be provided prior to surgery.
The list of procedures on this website is a partial list of procedures available in this pricing model. If the procedure you believe you require is not listed on this website, feel free to call our contact number to inquire about availability and pricing.
Once again, if you are scheduled for surgery at our facility and insurance is to be filed by us, these prices listed on our website do not apply to you.
Please review the Affordable Care Act Section 1557 Non-discrimination and Accessibility Requirements Policy.
Language Line: (877)386-9235