Patient Rights Under Florida Transparency Act Of 2016

Services Provided by ASC Surgery Center, a state-licensed health care facility.

The Eye Associates Surgery Center schedules patient care when your physician schedules a procedure for you at this surgery center.  The facility has one fee that covers the following items: Nursing, technician and related services; use of the facility; testing for certain lab tests performed at the surgery center just as glucose (blood sugar), pregnancy, and hemoglobin; medications administered before, during and after your surgery while in the facility; surgical supplies used by the physician and staff; equipment used in the facility; surgical dressings; implants except those specifically classified as premium implants that require additional patient payment.

Separate Providers

Services may be provided in this facility by the facility as well as by other health care providers who may separately bill the patient. Those separate health care providers may or may not participate with the same health insurers or health maintenance organizations (HMOs) as this facility. Patients and prospective patients should contact each health care provider who will provide services in the facility to determine the health insurers and HMOs with which the provider participates as a network provider or preferred provider.

Another health care provider who will bill you for services includes your physician performing the procedure. Other providers who will bill separately if  they provide you with health care services in this surgery center include an anesthesia provider who delivers anesthesia services to you at the facility and a pathology provider and laboratory which will analyze tissue your physician may require be sent to the laboratory to diagnose your condition.

You can contact the facility’s anesthesia providers about whether they participate in your health plan.  The anesthesia providers are

Name of anesthesia provider group: Bradenton Anesthesia Services

Mailing address: P.O.Box 636660 Cincinnati, OH 45263-6660

Telephone number: 1-866-631-7890

We may be required to send tissue for analysis by a pathology lab contracted with your health plan.  Your insurer’s provider network information may include the pathology lab in the insurer’s network of providers. You may want to check with your insurer.  Or, you can contact the laboratory directly about whether they participate in your health plan.

The pathology labs we send tissue to for analysis include

Name of pathology lab:Labcorp

Mailing address:P.O.Box 2240 Burlington, NC 27216

Telephone number: 1-800-845-6167

Website: www.labcorp.com

Name of pathology lab:Quest

Mailing address:P.O.Box 740698 Cincinnati,OH 45274

Telephone number: 1-866-697-8378

Website: www.questdiagnostics.com

Estimate of Charges

Patient or prospective patients may request from this facility and other health care providers an estimate of charges prior to receiving services. We must respond to you within seven days of your request.

Our estimate will be based upon the procedure your physician tells us that he or she plans to perform and the insurance information that you provide to us. We normally will contact your insurer to learn of your eligibility for the procedure and will then base our estimate upon what the insurer tells us about the payment they will make for the procedure.  The procedure your physician actually performs may differ from the initial one planned based upon your medical condition at the time of the procedure.  Since we cannot forecast the change, the estimate will be based upon the planned procedure as scheduled by your physician.

You may pay less or more for this procedure or service at another facility or in another health care setting.

Financial Assistance Arrangements

We only schedule procedures at this facility by physicians who are on the medical staff at the facility.  If your physician has determined that special financial assistance may be warranted and the physician agrees to those special financial arrangements for his or her services, you may be eligible for special financial assistance at the facility. If your physician or the physician’s office staff have agreed to provide special financial assistance to you for a procedure the physician wants to schedule at this facility, please contact us.

We will require you complete an application for financial assistance that provides us information about your income and expenses. This will allow us to access your need and qualifications for special financial assistance. Confirmation of eligibility includes verification of your household income through paycheck stubs,receipts for payment of mortgage or rent and utilities,last year’s tax filing, and information regarding changes since the last tax filing occurred. We follow the most recent poverty guidelines set by the U.S. Department of Health and Human Services.

Collections

Prior to your scheduled procedure, we will contact you with the results of the verification of your insurance benefits to advise of your insurance deductible and co-payment amounts that will be due from you prior to your surgery. We expect the amount estimate due to be paid on the day of your surgery when you register at our admission desk.

If you need special consideration for payment of the amount due, you must contact us prior to the date of the planned procedure so we can evaluate your eligibility. You may be eligible to pay your balance monthly over a period of three months. This is based upon your income and expenses that are verified per our charity care policy and take into consideration that, while you do not meet federal poverty guidelines for charity care, you may quality for a payment plan if we can verify your income is less than four times the federal poverty level.

If we received denial of payment from your insurer or Health Maintenance Organization, we will notify you. If we receive payment from your insurer or HMO that is less than projected, we will notify you of additional payment due. Payment will be expected within 15 days of notification of the balance due.  Failure to pay the balance due by the deadline will result in your account being turned over to a collection agency.

If you have notified us in advance that you have no insurance and will pay cash for your procedure, you may be eligible to receive a discount off the usual charge for payment of your estimated charges in advance of the scheduled procedure. You must attest that you have no insurance and you must pay the full estimated charges in advance. If the procedure performed by your physician differs from the one scheduled, you may owe the difference between the scheduled procedure and the actual procedure performed. The balance, if any, will be due within 15 days. Failure to pay the balance will result in any discount arrangement being null and void and a full payment will be due.