Patient Information

SUMMARY OF THE FLORIDA PATIENT’S BILL OF RIGHTS AND RESPONSIBILITIES

Florida law requires that your health care provider or health care facility recognize your rights while you are receiving medical care and that you respect the health care provider’s or health care facility’s right to expect certain behavior on the part of patients. You may request a copy of the full text of this law from your health car provider or health care facility. A summary of your rights and responsibilities follows:

• A patient has the right to be treated with courtesy and respect, with appreciation of his or her individual dignity and with protection of his or her need of privacy.
• A patient has the right to a prompt and reasonable response to questions and requests.
• A patient has the right to know who is providing medical services and who is responsible for his or her care.
• A patient has the right to know what patient support services are available, including whether and interpreter is available if he or she does not speak English.
• A patient has the right to know what rules and regulations apply to his or her conduct.
• A patient has the right to be given by his health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, and prognosis.
• A patient has the right to refuse treatment, except as otherwise provided by law.
• A patient has the right to be given, upon request full information and necessary counseling on the availability of known financial resources for his or her care.
• A patient who is eligible for Medicare has the right to know upon request and in advance of treatment whether the health care provider or health care facility accepts the Medicare assignment rate.
• A patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
• A patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have charges explained.
• A patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, physical handicap, or source of payment.
• A patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
• A patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental
• A patient has the right to express grievances regarding any violation of his or her rights, as stated in Florida law, through the grievance procedure of the health care provider or health care facility which served him or her and to the appropriate state licensing agency.
• A patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete infomation about present complaints, past illnesses, hospitalization, medications, and other matters relating to his or her health.
• A patient is responsible for reporting unexpected changes in his or her condition to the health care provider.
• A patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
• A patient is responsible for following the treatment plan, recommended by the health care provider.
• A patient is responsible for keeping appointments and , when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.
• A patient is responsible for his or her actions if he or she refuses treatment or dose not follow the health care provider’s instructions.
• A patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
• A patient is responsible for following health care and facility rules and regulations affecting patient care and conduct.

If you have a complaint against a hospital or ambulatory surgical center,
call the Consumer Assistance Unit at 1-888-419-3456. (Press 1) or write to the address listed below:

If you have a complaint against a health care professional and want to receive a complaint form,
call the Consumer Services Unit at 1-888-419-3456 (Press 2)

Or write to the address below:

RESUMEN Y RESPONSABILIDADES DE LOS DERECHOS CIVILES DE LOS PACIENTES DE LA FLORIDA

La ley de la Florida require qua su proveedor de salud, al igual que las facilidades reconozcan sus derechos mientras usted esta recibiendo Atencion medica, siempre y cuando listed respite las indicaciones de su proveedor de salud o de las facilidades de salud. Usted puede solicitor copia del texto complete de esta ley a su proveedor de salud o a sus facilidades de salud. Un resumen de sus derechos y responsabijlidades a continuacion:

• El paciente tiene derecho hacer tratado con cortesia y respecto con apreciacion de su dignidad individual y con la proteccion necesaria de su privacidad.
• El paciente tiene derecho a una respuesta rapida y razonable a sus preguntas y pedidos.
• El paciente tiene el derecho a saber quien prove los servicios medicos y quien es responsible por su cuidado.
• El paciente tiene el derecho a saber los servicios de apoyo al que tiene derecho y si existen los servicios de un interprete en caso de que no hable ingles.
• El paciente tiene el derecho a saber cuales reglas y regulaciones se aplican a su conducta.
• El paciente tiene el derecho a que el proveedor de salud le provea informacion respecto al diagnastico, tratamiento, riesgos, y alternatives.
• El paciente tiene el derecho de negar tratamiento, excepto aquellos que se proven por ley.
• El paciente tiene el derecho, si lo pide, a toda la informacion y la orientacion necesaria sobre los recursos financieros disponibles para su cuido.
• El paciente que es elegible para Medicare, tiene derecho a saber de ante mano, si el tratamiento de salud o las facilidades de cuido aceptan la tarifa design ada por Medicare.
• El paciente tiene el derecho a recibir un estimado resonable del costo ponatencion medica, si lo pide antes de recibir tratamiento.
• El paciente tiene el derecho a recibir copia clara del estado de cuenta y explicacion de las cargos, si asi lo pide.
• El paciente tiene el derecho a recibir tratamiento medico o acomodo, sin importer su raza, nacionalidad de origin, religion, impedimentolisico, o manera de pago.
• El paciente tiene el derecho a saber si el tratamiento medico es para propositos de investigacion experimental y dar su consentimiento o negar su participacion en tal investigacion experimental.
• El paciente tiene derecho a expresar cualqier que ja con relacion a violaciones de sus derechos ppr la ley de la Florida, a traves del procedimiento de quejas del proveedor de servicios de saludo o las failidades de cuido de la salud que atienda su caso y de la agencia del estado que otorga las licencias.
• El paciente es responsible de proveer informacion completa sobre su estado de salud a su major entendimiento, informacion completa acerca de que has recientes, pasadas enfermedades, hospitalizaciones, medicamentos, y otras causas relacionadas con su salud.
• El paciente es responsible por reportarle a su proveedor de salud cambios in esperados sobre su condicion de salud.
• El paciente es responsible por reportarle a su proveedor de salud si y pronosti ha considerado y entiende el curso de accion que va a tomar y lo que se espera de el.
• El paciente es responsible ha seguir el tratamiento de salud que la ha recomendado su proveedor de salud.
• El paciente es responsible por mantener sus citas, y si por alguna razon no puede mantenerlas, debe notificarselo a su proveedor de saludo o a la facilidad de salud.
• El paciente es responsible por sus acciones, en el negar de tratamiento y si no sigue las instrucciones proveedor de salud.
• El paciente es responsible de asegurarse que las obligaciones financieras por su cido de salud sean cumplidas lo mas rapido possible.
• El paciente es responsible ha seguir las reglas y regulaciones que afecten la conducta y el cuido de paciente.
• El paciente tiene el derecho a recibir tratamiento de emergencia por cualquier condicion medica que pueda empeorar si se le niega tratamiento.

Si usted tiene alguna queja contra el hospital o el centro quirurgico amblatorio, llame a la Unidad de Asistencia al Consumidor al
1-888-419-3456 (Presione el 1) o esonba a la siguiente direccion:

Si usted tiene alguna queja contra un professional del cuidado de la salud y quiere recibir un formulario de quejas, llame a la Unidad de Asistencia
Al Condumidor al 1-888-419-3456 (Presione el 2) o escriba a la siguiente direccion:

• Please bring your insurance card(s) and a picture ID the day of surgery.
• We participate in Medicare, Medicaid, Tricare,Worker's Compensation, and Americgroup Medicaid HMO.
• We accept all insurances with OUT OF NETWORK benefits and you will pay no more out-of-pocket than if you went into a facility in your insurance carrier's network.
• We will verify your insurance benefits and give you a written estimate of fees to include your out-of-pocket co-pay, co-insurance,and/or deductible before you have surgery.
• The Center's bill does not include fees for your surgeon, anesthesiologist, laboratory tests, pathology tests or other diagnostic tests ordered by your surgeon. Note: These fees are billed separately by those providers.

• If you have a change in your physical condition such as a cold,fever, or wound near the site of the scheduled surgery, notify your surgeon before coming to the surgery center.
• Arrange for a responsible adult to drive you home after your procedure and remain with you for the first 24 hours after discharge. For children (age 17 and younger) a responsible adult must accompany the patient at all times while at the Center.
• If you are on blood thinners, diabetic medications, high blood pressure medication or cardiac medications, check with your physician for instructions on your medications regimen.
• You will receive instructions on when to discontinue food and liquids prior to surgery. Be sure to follow these instructions completely or your surgery may be rescheduled.

• Bring a case for contact lenses, glasses, or removable dentures or bridgework for their safekeeping during your procedure.
• Bathe or shower to remove all makeup.Do not use lotions or oils after bathing.
• Wear comfortable shoes and loose fitting clothing such as sweat suits and easy to button tops. Bring warm socks.
• For Children: If your child has a favorite toy, blanket or possession that gives comfort, please bring it with you.
• Bring a list of medications and dosages you currently take.
• Leave all valuables, including jewelry and cash, at home. The Center is not responsible for damaged or lost property.
• A thorough preoperative assessment will occur upon admission.
• Anesthesia personnel will meet with you to discuss your anesthesia. They will explain to you exactly what will happen before, during and after your surgery. They will answer any questions you have before proceeding to the surgery suite.
• You will be provided with a personal belongings bag to secure your clothing. All valuables must be given to the responsible adult accompanying you to the Center.
• One family member or friend will be allowed to accompany you before and after surgery in the patient care areas.
• For Children: One or both parents will be allowed to accompany the child before and after surgery in the patient care areas.

• You will rest in our recovery room under the care of specially trained nurses.
• Your Anesthesiologist will monitor and be apprised of your condition while in the recovery room until you are discharged home.

• Even though you may feel fine, have someone stay the night with you.
• Do not make important decisions, consume alcohol, take medications not prescribed by your physician, or operate machinery during the 24 hour period following surgery.
• Remember, the recovery process continues even after you have returned home. You may experience minor after affects such as drowsiness, muscle aches, sore throat, and occasionally dizziness or headaches.
• Call your surgeon if you have questions about what you can or cannot do, or when you can return to regular activities. These items will be discussed when you receive your post-operative instructions.

• HTML version
• PDF version

• HTML version

Adult & Children's Surgery Center of SW FL facility fees cover the use of the facility only. The facility fees do not include laboratory, pathology, surgeon, or anesthesiologist fees. You will be billed separately for these services by the individual providers.

As a courtesy to our patients, we will bill your primary and secondary insurance carriers or governmental agency directly for the Adult & Children's Surgery Center of SW FL facility fees. On your day of surgery, please bring your most current insurance, Medicare, and/or Medicaid card with you.

Please be aware of any admission policies that your insurance plan may have as there may be certain requirements that must be met before your insurance company will pay for your procedure. Failure to obtain pre-authorization, physician referral, and/or a second opinion may result in your insurance benefits not paying for your procedure.

Be prepared to bring any co-pay or co-insurance payment on the day of your surgery. If you are a Self-Pay patient (you are paying for the entire procedure yourself), you will need to pay the total amount due on the day of your surgery. Please bring a photo ID with you. A photo ID is needed to complete your insurance validation.

For any payment due, we accept Cash, Check, Visa, MasterCard, Discover, American Express, Money Orders, Cashier's Checks, and Care Credit. If you require special financial arrangements, please contact Adult & Children's Surgery Center of SW FL Business Office to discuss alternative payments prior to you date of surgery. The number is (239) 936-9700.

If you have any questions and/or concerns regarding our facility fees, financial policy, or billing procedures, please contact the Business Office at (239) 936-9700.

While you are having your procedure in our center, you may have a procedure that requires a specimen. If a specimen is taken and sent to a pathologist, you will be billed directly from the Pathology Service.

AmeriPath
1620 Medical Ln, #100
Fort Myers, FL 33907


21Century
1860 Boy Scout Dr., Suite 204
Fort Myers, FL 33907
(239) 936-4507

The anesthesia that is provided for your procedure will be billed directly from Allegiant Anesthesia . You can contact them at (877) 822-6205 and they will be able to give you an estimate for your anesthesia costs.

If you need to know what the Estimated Fees are for your procedure, you may contact the Business Office at (239) 936-9700. You will need to have the procedure code (from your physicians office) that is being performed. Our staff will be able to enter the information and provide you with an Estimate of Facility Fees for your procedure. Please keep in mind that this is an estimate only and the final amount you owe may be more or less that what is estimated.