3325 Tamiami Trail, Ste. 100

Sarasota, FL 34239

PHYSICIAN OWNED FACILITY

The physicians listed below are on staff at the Center for Endoscopy providing medical services and are in fact the

owners of the facility and/or anesthesia and pathology companies. You may choose to have your surgery in a

facility not owned by physicians. By signing below you acknowledge that you have been given this option and

choose to have your surgery at The Center for Endoscopy.

Charles Loewe, MD Arun Khazanchi, MD Isaac Kalvaria, MD John Southerland, MD

ADVANCED DIRECTIVES

The Center for Endoscopy does not honor Advanced Directives. Unexpected complications due to anesthesia and/or

surgery are not natural causes and therefore will be treated. This means if an adverse event occurs during your

treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care

hospital for further evaluation. At the acute hospital, further treatment or withdrawal of treatment measures already

begun will be ordered in accordance with your wishes, Advance Directive, or Health Care Power of Attorney. The

admitting facility is not affiliated or in partnership with the Center for Endoscopy.

AUTHORIZATION TO PAY BENEFITS TO PHYSICIANS/FACILITY

I understand that my insurance company may send payments for the rendered services to me. I hereby assign to the

above named physicians all surgical, medical insurance, and/or other benefits, if any, otherwise payable to me for

their services at the Surgery Center. I agree to endorse the checks over to the facility. I understand that if I use the

insurance proceeds for my personal use, I have committed insurance fraud. I hereby authorize and direct payment

directly to the above named facility from the obligor of said benefits. Further, I hereby assign and convey to the

above named physicians/facility, unless charges for their services have been paid, so much of any cause of action or

right to recovery and any payment proceeds relating thereto, that I may have against any third party and direct my

attorney, if one has been retained as well as any person or insurance company obligated to pay damages or

restitution to me, to deduct the amount of any outstanding bill for the above named physician’s services from any

settlement proceeds or other proceeds to be paid directly to me, prior to receiving said proceeds.

GRIEVANCE PROCEDURE

The Center for Endoscopy values you as a patient. We are dedicated to ensuring your relationship with us is

positive one. If we can enhance that relationship in any way, please let us know. Every patient has the right to

express complaints about the care and services provided to any staff member. If the patient is not satisfied with the

resolution, the complaint is taken to the CEO. A formal grievance form can be obtained from the Receptionist.

Patients or the patient’s representative may also file a written complaint/grievance with the CEO at:

Center for Endoscopy

3325 Tamiami Trail, Ste. 100

Sarasota, FL 34239

(941) 552-3480

The CEO will be responsible for providing the patient with a written response within fourteen (14) days from the

date of receipt of the complaint or grievance. The patient has the right to complain to the following agencies if our

facility’s response is not satisfactory:

Florida State Department of Health Medicare Beneficiary Ombudsman

(850) 245-4339 (800) MEDICARE (800) 633-4273

www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html

By signing below, you, or your legal representative, acknowledge that you have received, read and

understand this information (verbally and in writing) in advance of the date of the procedure and have

decided to have your procedure performed at this center.

__________________________________________ ______________________________

Signature of Patient or Responsible Party Date

Center for Endoscopy FINANCIAL ASSIGNMENT

AUTHORIZATION AND RELEASE

I certify that the information supplied by me for applying for payment is correct. I authorize Center for Endoscopy to release any information about me needed for this claim. I request that the payment of authorized benefits be made on my behalf. I assign the benefit payable for issued directly to Center for the amount due in my pending claim for services of medical and/or surgical treatment.

I hereby authorize Center for Endoscopy to release to my representative, my attorney, other treating physician and my insurance company any information, including diagnosis and records for any treatment or examination rendered to me.

I understand that if a check is returned I will pay the Center the standard charges for a return check fee.

I understand that I am responsible for all fees related to my care and treatment and if my account is not paid in a timely manner on a monthly basis, my account may be turned over to a collection agency where I agree to pay all collection costs.

If uninsured I understand that financial arrangements must be made with the Center for Endoscopy Administrator or her/his designee prior to the procedure(s).

I authorize and request the release of medical records to the Center for Endoscopy from my primary care physician and/or referring physician for the purpose of continued medical treatment, payment, insurance, or legal purposes.

I authorize and voluntarily consent to disclose all information or medical records of my health care at the Center for Endoscopy to my primary care and/or referring physician.

I understand that this consent can be revoked by me in writing at any time except to the extent this action has already occurred.

I have read, understand, and agree to the above Authorization and Release:

Signature: X_________________________________________________ Date: _________________

FINANCIAL ASSIGNMENT AND AGREEMENT

Please remember that insurance is considered a method of reimbursement for fees. My authorization above assigns payment directly to the Center for Endoscopy. This is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is my responsibility to pay any deductible amount, co-insurance, co-pay as required by my insurance company.

I understand that my insurance policy is a contract between my insurance company and me. The Center is not a party to my contract and my insurance company. I understand that I am ultimately responsible for any and all balances, even if my insurance company agrees to pay and fails to do so.

I request that payment of authorized Medicare and/or insurance benefits be made on my behalf for any services furnished me. I authorize any holder of medical information about me to release to the Health Care Financing Administration, its agents, or any insurance carrier I may have, any information needed to determine these benefits or the benefits payable for related services.

This agreement will remain in effect until revoked by me in writing. I hereby authorize to release all information necessary to secure the payment. A photocopy of this assignment is to be considered as valid as an original.

I have been notified that Medicare may deny payment for any services that it does not deem “reasonable and necessary” under program standards, if Medicare denies payment I agree to be personally and fully responsible for payment.

I have read, understand, and agree to the above Financial Assignment:

Signature: X_________________________________________________ Date: _________________

If this document was signed by someone other than the patient, please state the reason the patient was unable to sign: ___________________________________________________________

Title/Relationship: ____________________________________________

PATIENT LABEL

606942/1

SunCoast Anesthesia Partners, LLC

PO BOX 864732Orlando, FL 32886-47321 888-337-3509 or 941-209-5410

The surgery or procedure you have had or are about to receive has at least three (4) separately billable components which consist of:

The professional services of the surgeon;

The professional services of the anesthesia provider (CRNA and/or physician), and

The facility fee (for use of the surgical or procedural site).

Pathology services

SunCoast Anesthesia Partners, LLC (SAP) provides the professional anesthesia services and Innovative Practice Strategies (IPS) is the billing agent for SAP. Anesthesia is commonly a covered component of your surgery or procedure. As a courtesy to you, the bill/claim for your anesthesia services, as well as any subsequent appeals, will be filed on your behalf directly with your primary insurance carrier. We, SAP and IPS, accept assignment of benefits and your insurance carrier should send the payment directly to the remittance address above. If we have secondary insurance information about you, we will file a claim on your behalf with that insurer for the amount not paid by your primary insurance. If no secondary insurance information is provided at the time of service, we will send you a statement for the co-insurance amount due according to your primary insurance carrier. You will be responsible for the deductible and/or co-pay amounts determined by your policy/plan.

In the event that SAP is not a participating provider with your insurance plan, IPS will work with your insurance carrier through various appeal efforts in order to minimize any penalties or costs that your insurance says that you owe. We are often able to negotiate with your insurer to reduce your out-of-pocket expenses due to SAP out-of-network status, but we cannot guarantee a result. You will also be required to pay the deductible and/or co-pay amounts determined by your policy/plan.

In order for us to communicate and correspond with your insurer about your surgery or procedure, we need you to give us permission to do so. Please read and sign the authorizations below which allow us to use and/or disclose your personal health information to your insurer and to take action on your behalf, as your representative, for the purposes of obtaining reimbursement and to prepare and manage appeals of coverage determination. These steps allow us to reduce your out-of-pocket expense as much as possible.

By signing this authorization, I authorize Innovative Practice Strategies, LLC (“IPS”) and/or SAP to use and/or disclose certain protected health information (PHI) about me to or for the party or parties listed below. This authorization permits IPS and/or SAP to use or disclose to my insurance company: _______________________________________________ any individually identifiable health information related to my surgery or procedure that took place on __________ at the Center for Endoscopy. I retain the right to revoke this authorization at any time; however, such revocation shall not affect actions that IPS has already undertaken prior to my revocation in order to process my claim. By signing this authorization, I hereby appoint IPS and/or SAP to act on my behalf as my authorized representative for all claims, services, and appeals related to my surgery or procedure that took place on __________at the Center for Endoscopy.

By signing this authorization, I request that payment of authorized benefits be made on my behalf to IPS and/or SAP for any services or goods provided by SAP. I authorize the release of any and all medical information that is necessary to process claims arising from the services herein referenced. I understand that some, and perhaps all, of the services may be determined by my insurance carrier, which cannot practice medicine, to be non-covered services and that such services may not be considered medically necessary under my insurance contract, regardless of how appropriate or medically necessary they may be. I understand that I am responsible for payment of any charges in full including non-covered services and deductible and/or co-payment amounts determined by my insurance to be due from me. IPS and/or SAP will not request a pre-authorization from your insurance company for procedures provided by IPS and/or SAP. I understand that it is my responsibility to insure that prior authorization for anesthesia services, if required, is on file with IPS and/or SAP prior to my receiving anesthesia services from SAP. I understand that I am responsible for payment in full of all charges submitted by IPS to my insurance company if prior authorization for anesthesia services was required and not obtained.

I acknowledge that I am voluntarily completing this authorization and affirm that no undue forces were utilized to obtain my cooperation. Signature: ___________________________Print Name: ____________________________________Date: ___________ Witness: ____________________________Signature:______________________________________Date: ___________ Patient Label

Center for Endoscopy MEDICAL HISTORY 3325 Tamiami Trail, Suite 100, Sarasota, FL 34239 PRE-ANESTHESIA EVALUATION Phone: 941-552-3480 Fax: 941-552-3485

____________________________________________ _______________________ Patient Name Phone cell / work

Respiratory System – Are you currently being treated or do you

have a history of the following:

Yes

No

Date

Comments

Asthma

Tuberculosis

Emphysema

Chronic Obstructive Pulmonary Disease (COPD)

Recent respiratory infection

Shortness of breath

Bronchitis

Cough

Difficulty swallowing foods or liquids

Do you have sleep apnea? C-PAP?

Smoke or have a history of smoking? How long and how much?

Do you drink alcohol? Type and amount?

Do you use recreational drugs? Type and frequency?

Do you exercise Type and frequency?

Heart and Vascular Systems – Are you currently being treated or do you have

a history of the following:

Yes

No

Date

Comments

Chest pain or angina

Congestive heart failure

Heart attack Cardiologist:

Irregular heart beat Cardiologist:

Seizures

Fainting spells

High blood pressure

Low blood pressure

Pacemaker Manufacturer: Automatic Implanted Cardioverter Defibrillator (AICD)

Stroke or TIA Any weakness?

Fluid or infection around the heart

Valve replacement Cardiologist:

Mitral valve prolapse / Heart murmur

Endocarditis / Pericarditis

Rheumatic fever

Open heart bypass surgery

Angioplasty How many stents? Deep Vein Thrombosis or Pulmonary Embolism

Treatment?

Recent falls (within last 3 months) Cause?

Reproductive System – do you have a

history of the following:

Yes

No

Date

Comments

Menopause How long?

Hysterectomy

PLEASE TURN OVER TO COMPLETE PATIENT LABEL

Ht: Wgt: Date/Time of Procedure: Procedure: Physician:

Date of Birth

Sex: [ ] Female [ ] Male

Marital Status: [ ] Single [ ] Married [ ] Divorced [ ] Widowed

Driver/Caregiver: Phone:

Age Do you know your Colon Prep?

[ ] NA [ ] Osmo [ ] Suprep [ ] Movi [ ] Miralax [ ] Prepopik

[ ] Other

General Systems – Are you currently

being treated or do you have a history of the following:

Yes

No

Date

Comments

Diabetes

Kidney disease Dialysis?

Thyroid trouble

Hepatitis Which type?

Paralysis

Glaucoma

Macular degeneration

Cancer Treatments?

HIV or AIDS

Anemia

Arthritis Where?

Dentures or partials

Hearing aids

Glasses or contacts

Artificial joints or grafts Where?

Are you allergic to rubber gloves or

balloons?

Do you bruise or bleed easily?

Do you have symptoms of heartburn,

indigestion, or acid/burning in the back of

your throat?

What medication do you take to treat this?

Do you use a walker, cane, or wheelchair? Which?

Any surgical procedures within the past 6

months?

Prior Endoscopy Procedures? Which Type?

Prior surgical complications?

Any disease or condition you were told you had but not listed here?

Any unusual reaction to anesthesia by you

or a family member?

Do you have an active infection?

Recent fever? If yes – recent travel?

Please list all medications, over the counter medications, and

vitamins – include the strength

Frequency

Allergies Type of Reaction

Nurse notes: [ ] Pre-operative instructions reviewed with patient. [ ] Confirmed patient understands they will be unable to drive For 24 hours after your procedure. [ ] Colon prep instructions reviewed, if applicable. [ ] Educated pt. on need to bring lip balm. [ ] Confirmed ride/Escort: _____________________________ [ ] Taxi: Caregiver: __________________________________ Contact Information: _______________ ______________ Confirmed patient received verbal/written Advanced Directive, Disclosure, Pt Rights & Responsibilities: [ ] MD office [ ] Pre-registration [ ] Website Pt. has Advance Directive: Yes [ ] No [ ]

Patient instructed to bring it in with them: Yes [ ] No [ ]

RN: ___________________________________________

Date Completed/reviewed with patient: ______________

PATIENT LABEL

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

CAREFULLY.

Understanding Your Health Record Information

Each time that you visit a hospital, a physician, or another health care provider, the provider makes a record of your

visit. Typically, this record contains your health history, current symptoms, examination and test results, diagnoses,

treatment, and plan for future care or treatment. This information, often referred to as your medical record, serves as

the following:

Basis for planning your care and treatment.

Means of communication among the many health professionals who contribute to your care.

Legal document describing the care that you received.

Means by which you or a third-party payer can verify that you actually received the services billed for.

Tool in medical education.

Source of information for public health officials charged with improving the health of the regions that they serve.

Tool to assess the appropriateness and quality of care that you received.

Tool to improve the quality of health care and achieve better patient outcomes.

Understanding what is in your health record and how your health information is used helps you to—

Ensure its accuracy and completeness.

Understand who, what, where, why, and how others may access your health information.

Make informed decisions about authorizing disclosure to others.

Better understand the health information rights detailed below.

Your Rights under the Federal Privacy Standard

Although your health records are the physical property of the health care provider who completed the records, you

have the following rights with regard to the information contained therein:

Request restriction on uses and disclosures of your health information for treatment, payment, and health care

operations. “Health care operations” consist of activities that are necessary to carry out the operations of the

provider, such as quality assurance and peer review. The right to request restriction does not extend to uses or

disclosures permitted or required under the following sections of the federal privacy regulations: §

164.502(a)(2)(i) (disclosures to you), § 164.510(a) (for facility directories, but note that you have the right to

object to such uses), or § 164.512 (uses and disclosures not requiring a consent or an authorization). The latter

uses and disclosures include, for example, those required by law, such as mandatory communicable disease

reporting. In those cases, you do not have a right to request restriction. The consent to use and disclose your

individually identifiable health information provides the ability to request restriction. We do not, however, have to

agree to the restriction, except in the situation explained below. If we do, we will adhere to it unless you request

otherwise or we give you advance notice. You may also ask us to communicate with you by alternate means, and

if the method of communication is reasonable, we must grant the alternate communication request. You may

request restriction or alternate communications on the consent form for treatment, payment, and health care

operations. If, however, you request restriction on a disclosure to a health plan for purposes of payment or health

care operations (not for treatment), we must grant the request if the health information pertains solely to an item or

a service for which we have been paid in full.

Obtain a copy of this notice of information practices. Although we have posted a copy in prominent locations

throughout the facility and on our website, you have a right to a hard copy upon request.

Inspect and copy your health information upon request. Again, this right is not absolute. In certain situations, such

as if access would cause harm, we can deny access. You do not have a right of access to the following:

o Psychotherapy notes. Such notes consist of those notes that are recorded in any medium by a health care

provider who is a mental health professional documenting or analyzing a conversation during a private, group,

joint, or family counseling session and that are separated from the rest of your medical record.

o Information compiled in reasonable anticipation of or for use in civil, criminal, or administrative actions or

proceedings.

o Protected health information (“PHI”) that is subject to the Clinical Laboratory Improvement Amendments of

1988 (“CLIA”), 42 U.S.C. § 263a, to the extent that giving you access would be prohibited by law.

o Information that was obtained from someone other than a health care provider under a promise of

confidentiality and the requested access would be reasonably likely to reveal the source of the information.

o Information that is copyright protected, such as certain raw data obtained from testing.

In other situations, we may deny you access, but if we do, we must provide you a review of our decision

denying access. These “reviewable” grounds for denial include the following:

o A licensed health care professional, such as your attending physician, has determined, in the exercise of

professional judgment, that the access is reasonably likely to endanger the life or physical safety of yourself or

another person.

o PHI makes reference to another person (other than a health care provider) and a licensed health care provider

has determined, in the exercise of professional judgment, that the access is reasonably likely to cause

substantial harm to such other person.

o The request is made by your personal representative and a licensed health care professional has determined, in

the exercise of professional judgment, that giving access to such personal representative is reasonably likely to

cause substantial harm to you or another person.

For these reviewable grounds, another licensed professional must review the decision of the provider denying

access within 60 days. If we deny you access, we will explain why and what your rights are, including how to seek

review. If we grant access, we will tell you what, if anything, you have to do to get access. We reserve the right to

charge a reasonable, cost-based fee for making copies.

Request amendment/correction of your health information. We do not have to grant the request if the following

conditions exist:

o We did not create the record. If, as in the case of a consultation report from another provider, we did not

create the record, we cannot know whether it is accurate or not. Thus, in such cases, you must seek

amendment/correction from the party creating the record. If the party amends or corrects the record, we will

put the corrected record into our records.

o The records are not available to you as discussed immediately above.

o The record is accurate and complete.

If we deny your request for amendment/correction, we will notify you why, how you can attach a statement of

disagreement to your records (which we may rebut), and how you can complain. If we grant the request, we will

make the correction and distribute the correction to those who need it and those whom you identify to us that you

want to receive the corrected information.

Obtain an accounting of non-routine uses and disclosures, those other than for treatment, payment, and health care

operations until a date that the federal Department of Health and Human Services will set after January 1, 2011.

After that date, we will have to provide an accounting to you upon request for uses and disclosures for treatment,

payment, and health care operations under certain circumstances, primarily if we maintain an electronic health

record. We do not need to provide an accounting for the following disclosures:

o To you for disclosures of protected health information (“PHI”) to you.

o For the facility directory or to persons involved in your care or for other notification purposes as

provided in § 164.510 of the federal privacy regulations (uses and disclosures requiring an

opportunity for the individual to agree or to object, including notification to family members, personal

representatives, or other persons responsible for your care of your location, general condition, or

death).

o For national security or intelligence purposes under § 164.512(k)(2) of the federal privacy regulations

(disclosures not requiring consent, authorization, or an opportunity to object).

o To correctional institutions or law enforcement officials under § 164.512(k)(5) of the federal privacy

regulations (disclosures not requiring consent, authorization, or an opportunity to object).

o That occurred before April 14, 2003.

We must provide the accounting within 60 days. The accounting must include the following information:

o Date of each disclosure.

o Name and address of the organization or person who received the protected health information.

o Brief description of the information disclosed.

o Brief statement of the purpose of the disclosure that reasonably informs you of the basis for the

disclosure or, in lieu of such statement, a copy of your written authorization or a copy of the written

request for disclosure. The first accounting in any 12-month period is free. Thereafter, we reserve the

right to charge a reasonable, cost-based fee.

Revoke your consent or authorization to use or disclose health information except to the extent that we have taken

action in reliance on the consent or authorization.

Our Responsibilities under the Federal Privacy Standard

In addition to providing you your rights, as detailed above, the federal privacy standard requires us to take the

following measures:

Maintain the privacy of your health information, including implementing reasonable and appropriate physical,

administrative, and technical safeguards to protect the information.

Provide you this notice as to our legal duties and privacy practices with respect to individually identifiable health

information that we collect and maintain about you.

Abide by the terms of this notice.

Train our personnel concerning privacy and confidentiality.

Implement a sanction policy to discipline those who breach privacy/confidentiality or our policies with regard

thereto.

Mitigate (lessen the harm of) any breach of privacy/confidentiality.

We will not use or disclose your health information without your consent or authorization, except as described in this

notice or otherwise required by law. These include most uses or disclosures of psychotherapy notes, marketing

communications, and sales of PHI. Other uses and disclosures not described in this notice will be made only with your

written authorization

Examples of Disclosures for Treatment, Payment, and Health Care Operations

We may use your health information for treatment.

Example: A physician, a physician’s assistant, a therapist or a counselor, a nurse, or another member of your health

care team will record information in your record to diagnose your condition and determine the best course of treatment

for you. The primary caregiver will give treatment orders and document what he or she expects other members of the

health care team to do to treat you. Those other members will then document the actions that they took and their

observations. In that way, the primary caregiver will know how you are responding to treatment. We will also provide

your physician, other health care professionals, or a subsequent health care provider copies of your records to assist

them in treating you once we are no longer treating you. Note that some health information, such as substance abuse

treatment information, may not be used or disclosed without your consent.

We may use your health information for payment.

Example: We may send a bill to you or to a third-party payer, such as a health insurer. The information on or

accompanying the bill may include information that identifies you, your diagnosis, treatment received, and supplies

used. Note that some health information, such as substance abuse treatment information, may not be used or disclosed

without your consent.

We may use your health information for health care operations.

Example: Members of the medical staff, the risk or quality improvement manager, or members of the quality

assurance team may use information in your health record to assess the care and outcomes in your cases and the

competence of the caregivers. We will use this information in an effort to continually improve the quality and

effectiveness of the health care and services that we provide. Note that some health information, such as substance

abuse treatment information, may not be used or disclosed without your consent

Business associates.

We provide some services through contracts with business associates. Examples include certain diagnostic tests, a

copy service to make copies of medical records, and the like. When we use these services, we may disclose your

health information to the business associates so that they can perform the function(s) that we have contracted with

them to do and bill you or your third-party payer for services provided. To protect your health information, however,

we require the business associates to appropriately safeguard your information. After February 17, 2010, business

associates must comply with the same federal security and privacy rules as we do.

Directory. Unless you notify us that you object, we may use your name, location in the facility, general

condition, and religious affiliation for directory purposes. This information may be provided to members of the

clergy and, except for religious affiliation, to other people who ask for you by name.

Notification. We may use or disclose information to notify or assist in notifying a family member, a personal

representative, or another person responsible for your care, location, and general condition.

Communication with family. Unless you object, we, as health professionals, using our best judgment, may

disclose to a family member, another relative, a close personal friend, or any other person that you identify health

information relevant to that person’s involvement in your care or payment related to your care.

• Research. We may disclose information to researchers when their research has been approved by an

institutional review board that has reviewed the research proposal and established protocols to ensure the

privacy of your health information.

Funeral directors. We may disclose health information to funeral directors consistent with applicable law to

enable them to carry out their duties.

Marketing/continuity of care. We may contact you to provide appointment reminders or information about

treatment alternatives or other health-related benefits and services that may be of interest to you. If we contact you

to provide marketing information for other products or services, you have the right to opt out of receiving such

communications. Contact the Privacy Officer at 941-552-3480. If we receive compensation from another entity for

the marketing, we must obtain your signed authorization.

Fundraising. We may contact you as a part of a fundraising effort. You have the right to request not to receive

subsequent fundraising materials. Contact the Privacy Officer at 941-552-3480.

Food and Drug Administration (“FDA”). We may disclose to the FDA health information relative to adverse

effects/events with respect to food, drugs, supplements, product or product defects, or post marketing surveillance

information to enable product recalls, repairs, or replacement.

Workers compensation. We may disclose health information to the extent authorized by and to the extent

necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public health. As required by law, we may disclose your health information to public health or legal authorities

charged with preventing or controlling disease, injury, or disability.

Correctional institution. If you are an inmate of a correctional institution, we may disclose to the institution or

agents thereof health information necessary for your health and the health and safety of other individuals.

Law enforcement. We may disclose health information for law enforcement purposes as required by law or in

response to a valid subpoena.

Health oversight agencies and public health authorities. If members of our work force or business associates

believe in good faith that we have engaged in unlawful conduct or otherwise violated professional or clinical

standards and are potentially endangering one or more patients, workers, or the public, they may disclose your

health information to health oversight agencies and/or public health authorities, such as the Department of health.

The federal Department of Health and Human Services (“DHHS”). Under the privacy standards, we must

disclose your health information to DHHS as necessary to determine our compliance with those standards.

WE RESERVE THE RIGHT TO CHANGE OUR PRACTICES AND TO MAKE THE NEW PROVISIONS

EFFECTIVE FOR ALL INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION THAT WE MAINTAIN. IF

WE CHANGE OUR INFORMATION PRACTICES, WE WILL MAIL A REVISED NOTICE TO THE ADDRESS

THAT YOU HAVE GIVEN US.

________________________________________________ ____________________

Patient Signature Date

Patient Label

Center for Endoscopy PATIENT INFORMATION

Name: _______________________________________________________________________________________________ First Middle Initial Last

Address: ____________________________________________________________________________ZIP: ______________________

Other Address: _________________________________________________________________________________________________

Social Security Number: _________- ________- ______________ Date of Birth: ___________________________ Sex: [ ] Female

Home Phone: (________) ___________________________ Other Phone: (________) _________________________ [ ] Male Email Address: _________________________________________________

Marital Status: [ ] Single Race: [ ] White [ ] Asian Ethnicity: [ ] Hispanic/ Latino [ ] Married [ ] African American [ ] American Indian/ Native Alaskan [ ] Non Hispanic/ Latino [ ] Widow [ ] Hispanic [ ] Native Hawaiian/ Pacific Islander [ ] Other [ ] Divorced/Separated [ ] Other

Primary Care Physician: __________________________________________________________________________________________

Physician who should receive a copy of your procedure report: ____________________________________________________________

Advance Directive Have you executed an advanced directive? Yes No

You will be accepted for care whether or not you have an advance directive. However, should you become Incapable of making medical decisions during your admission and you do not have an advance directive; The Center is required to find someone (a proxy) to make decisions for you.

I appoint ___________________________________________________ to make medical decisions if I become Incapable of doing so.

Relationship: _________________________________________ Phone: ___________________________________

Signature: X_____________________________________ Date: _________________________________

_______________________________________________________________________________

Restriction of Protected Health Information

In accordance with the Center for Endoscopy’s Privacy Practices and to protect the confidentiality of my protected Health information, I hereby direct that disclosure of my protected health information be restricted. Specifically, no documentation of any information related to my stay or treatment, management, or quality assurance purposes, is to be disclosed under any circumstances, redacted or otherwise, to anyone not affiliated with the Center for Endoscopy, for any purpose other than payment or licensure/accreditation requirements, without my express written consent or the express written consent of my authorized representative. I understand that this Directive in no way limits my right to access any and all records related to my own medical care and treatment in the health system.

Signature: X_____________________________________ Date: ___________________________

OVER

INSURANCE INFORMATION MUST BE FILLED OUT

Primary Insurance: ___________________________________________________ ID #___________________________________________

Name of Insured if other than self: ______________________________________________________________________________________

Date of Birth: _______/_______/___________ Social Security Number: ___________-________-_____________

INSURANCE INFORMATION MUST BE FILLED OUT

Secondary Insurance: ________________________________________________ ID #___________________________________________

Name of Insured if other than self: ______________________________________________________________________________________

Date of Birth: _______/_______/___________ Social Security Number: ___________-________-_____________

Center for Endoscopy ABUSE HOTLINE 1-800-962-2873 Medicare Ombudsman: www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html PATIENT’S RIGHTS: This facility and medical staff have adopted the following list of patient rights. This list shall include, but not be limited to, the patient’s rights to:

• A patient shall be accorded impartial access to treatment or accommodations that are available or medically indicated, regardless of race, creed, sex, national origin, or sources of payment for care.

• 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 an 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 their health care provider information concerning diagnosis, planned course of

treatment, alternatives, risks, and prognosis. • A patient has the right to refuse treatment, except and 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 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 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 research. • A patient has the right to express grievances regarding any violation of their rights, as stated in Florida law, through the

grievance procedure of the facility which served them and to the appropriate state licensing agency. • A patient has the right to refuse to participate in experimental research. • A patient has the right to file a grievance through the Center’s formal grievance process. • A patient has the right to have an advance directive concerning treatment to the extent permitted by law.

PATIENT’S RESPONSIBILITIES: The care a patient receives depends particularly on the patient himself/herself. Therefore, in addition to these rights, a patient has certain responsibilities as well.

• A patient is responsible for providing to the health care provider, to the best of their knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications, and other matters relating to their health.

• A patient is responsible for reporting unexpected changes in their condition to the health care provider. • A patient is responsible for reporting to the health care provider whether they comprehend a contemplated course of

action and what is expected of them. • A patient is responsible for following the treatment plan recommended by the health care provider. • A patient is responsible for keeping appointments and when they are unable to do so for any reason, for notifying the

health care provider or facility. • A patient is responsible for their actions if they refuse treatment or for not following the health care provider’s instructions. • A patient is responsible for assuring that the financial obligations of their 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.

__________________________________________ ______________________________ Signature of Patient or Responsible Party Date

Suncoast Anesthesia Partners, LLC, PO Box 919368 Orlando, FL 32891-9368

SunCoast Anesthesia Partners, LLC

PO Box 919368

Orlando, FL 32891-9368

Dear Surgery Patient:

The surgery you have had or are about to receive has potentially FOUR (4) separately

billable components which consist of:

1. The professional services of the surgeon;

2. The professional services of the certified registered nurse anesthetist and/or

anesthesiologist, and the anesthesia staff; and

3. The facility fee (for use of the surgery center proper).

4. Pathology

Each of the entities providing services is a separate company, and cannot answer billing

questions for the other, so please contact the appropriate company for billing related concerns.

SunCoast Anesthesia Partners, LLC. will be providing the anesthesia services listed in item 2

Anesthesia is commonly a covered component of your surgery. As a courtesy to you, the

bill/claim for your anesthesia services will be filed directly to your primary insurance carrier. We

have accepted assignment of benefits and your insurance carrier should send the payment directly

to our remittance address below. If we have a secondary insurance on file, we will file a claim on

your behalf for the amount not paid by your primary insurance. If no secondary insurance was

provided at the time of service, we will send you a statement for the co-insurance due as

determined by your insurance carrier. You will be responsible for your designated deductible

and/or co-pay as determined by your policy/plan.

In the event that SunCoast Anesthesia Partners, LLC is not a participant within your

insurance plan, we will work with your carrier through appeal efforts to minimize any penalties to

your due to our non-participating (i.e., out-of-network) status. We are often able to negotiate with

your insurer to allow minimal or no out-of-pocket costs to you due to our out-of-network status,

but we cannot guarantee this result. The amount you may owe will be within the participating

benefit rate limits in your area. You will also be required to pay your designated deductible and/or

co-pay as determined by your policy/plan.

If your insurance carrier sends payment directly to you, please endorse the back of the check and list “Pay to the order of Innovative Pain Solutions, LLC” above your signature, or, write a personal check for the amount received. Please forward payment & explanation of benefits to the name and address listed below. (The explanation of benefits received with payment.) If you have any questions or concerns, please contact us at 1-888-337-3509.

ASSIGNMENT OF BENEFITS I hereby assign the benefits due to me through my insurer to Suncoast Anesthesia Partners, LLC, for the service rendered. I understand that these charges are separate from the surgeon’s fees and/or facility fee. I authorize and instruct my insurance carrier to release all records required to process my claims(s) and to make payments directly to Suncoast Anesthesia Partners, LLC. This permission is also granted to these parties for Medicare claims filed under Title XVIII of the Social Security Act. Signature of Patient/representative Date