Welcome Packet

Welcome To Brookside Surgery Center Thank you for choosing Brookside Surgery Center for your outpatient surgery needs. It is our pleasure to provide a cost-effective, efficient, and safe alternative for outpatient surgery in the Battle Creek, Michigan area. We look forward to serving you.

Our pre-admission nurse will contact you prior to your surgery to discuss your medical history and medications including dosage and frequency. She will inform you of what medications to take on the day of surgery as well as answer any questions you may have.

Unless otherwise instructed by your surgeon, primary care physician, cariologist, or our preadmission nurse, you will need to stop any Aspirin, anti-inflammatories, blood thinners, vitamin E or fish old, and all herbal supplements 5 days before surgery. All weight loss medications must be stopped at least 7 days prior to surgery. If you are having cataract surgery, you do not have to stop any medication, unless directed by your physician. If you are unsure about any medications, you are currently taking, please check with your prescribing physician.

It is extremely important that you DO NOT eat or drink anything, including water, after midnight the night prior to your surgery, unless otherwise directed by your physician or the preadmission nurse. Chewing gum, lozenges, mints, and coffee are also prohibited.

We look forward to providing you with excellent care during your upcoming surgery.

Thank you,
The Staff of Brookside Surgery Center

NOTICE OF PATIENT INFORMATION PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO INFORMATION. PLEASE REVIEW CAREFULLY.

BROOKSIDE SURGERY CENTER’S LEGAL DUTY

Brookside Surgery Center is required by law to protect the privacy of your personal health information, provide this notice about our information practices and follow the information practices that are described herein.

USES AND DISCLOSURES OF HEALTH INFORMATION

Brookside surgery center uses your personal health information primarily for treatment; obtaining payment for treatment; conducting internal administration activities and evaluating the quality of care that we provide. For example, Brookside Surgery Center may use your personal health information to contact you to provide appointments reminders or other health related information that could be of interest to you.

Brookside Surgery Center may also use or disclose your personal health information without prior authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We also provide information when required by law.

In any other situation, Brookside Surgery Center’s policy is to obtain your written authorization before disclosing your personal health information. If you provide us with a written authorization to release your information for any reason, you may later revoke that authorization to stop future disclosures at any time.

Brookside Surgery Center may change its policy at any time. When changes are made, a new notice of information practices will be posted in the waiting room and patient exam areas and will be provided to you on your next visit. You may also request an updated copy of our notice of information practices at any time.

PATIENT’S INDIVIDUAL RIGHTS

You have the right to review or obtain a copy of your personal health information at any time. You have the right to request that we correct any inaccurate or incomplete information in your records. You also have the right to request a list of instances where we have disclosed your personal health information for reasons other than treatment, payment, or other related administrative purposes.

You may also request in writing that we do not use or disclose your health information for treatment, payment, and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. Brookside Surgery Center will consider all such requests on a case-by-case basis, but the practice is not legally required to accept them.

CONCERNS AND COMPLAINTS

If you are concerned that Brookside Surgery Center may have violated your privacy rights or if you disagree with any decisions we have made regarding access or disclosure of your personal health information, please contact our practice manager at the address listed below. You may also send or call in a complaint to the U.S. Department of Health and Human Services/ 200 independence Avenue SW / Washington, D.C. 20201. For further information on Brookside Surgery Center / 3600 Capital Avenue SW, Suite 101. Battle Creek, MI 49015 / (269)979-2490.

Your Rights and Responsibilities as a Brookside Surgery Center Patient

You have the RIGHT as a patient or client:

• To receive care that respects your individual cultural, spiritual and social values, regardless of race, color, creed, nationality, age, gender, disability, or source of payment.
• To request and receive medically appropriate treatment and services within the surgery facility’s capacity and mission and to know what services are available at the organization.
• To receive respectful, considerate, compassionate care that manages your pain as well as possible, and promotes dignity, privacy, safety, and comfort.
• To receive a full explanation, in understandable language, diagnosis, evaluation, treatment and prognosis in terms that are easily understood and that include benefits, risks involved, significant complications, and the outcome and alternative treatments available.
• When it is medically inadvisable to give such information to a patient, the information is provided to a person designated by the patient or to a legally authorized person. This person shall receive all the patient’s rights and responsibilities and shall exercise these rights.
• To expect that efforts will be made to provide you with the best of care during and after your procedure.
• To know at all times, the identity and professional status of all individuals providing any type of service. To request a second opinion or change physicians if other qualified providers are available. To know the credentials of the health care professionals providing your care. To be aware that the facility and its credentials of the health care professionals providing your care. To be aware that the facility and its healthcare providers have malpractice insurance coverage.
• To participate in the decisions about your medical care and receive prompt/reasonable responses to questions or requests, except when such participation is contraindicated for medical reasons. To accept or refuse recommended tests or treatments to the extent the law permits. To refuse to sign a consent form if there is anything you do not understand or agree to. To change your mind about any procedure to which you have consented.
• To receive services that are accessible to those individuals with communications barriers such as visual impairment, hearing impairments, communication disorders, inability to read or follow directions, and non-English speakers.
• To be informed and to give or withhold consent if our facility proposes to engage in or perform research associated with your care or treatment.
• To be informed of advance directives specific to the state of operation.
• To expect that your advance directives/living will is honored when ethically possible and in accordance with state law. o However, the facility WILL NOT honor a DNR (Do Not Resuscitate). In an emergency, we will act to employ all life saving measures while you are under our care.
• To have patient disclosures and records treated confidentially, and patients are given the opportunity to approve or refuse their release, expect when release is required by law.
• To receive marketing materials from the facility that are accurate and not misleading to receive accurate reflection of the facility’s accreditation standing with AAAHC.
• To be made aware of our fee for services and payment policies.
• The right to voice grievances, written and/or verbal regarding treatment of care that is (or fails to be) furnished.
• To be informed of available resources for resolving disputes, grievances, and conflicts; without fear of reprisal, and to be free from all forms of abuse (verbal, mental, sexual, or physical) mistreatment, neglect, harassment, or discrimination, and have access to facility level, state and federal assistance in clarifying ethical issues guiding treatment decisions.
• To know that all alleged violations/grievances will be fully documented.
• To know that all allegations must be immediately reported to a person in authority in the ASC.
• To know that only substantiated allegations must be reported to the state authority or local authority, or both. To participate in the resolution of those issues.
• To ask that your medical record be corrected if you believe it is not accurate or not complete, or to be told how to add a statement that you disagree with information in the record.

PATIENT RESPONSIBILITIES

These responsibilities apply to patients, family members, significant others, and/or decisionmakers when they are acting for the patient.

You have the Responsibility:

• To answer questions about your past illnesses, hospital stays, medicines, and other health matters when asked by a doctor or staff member; to include over-the-counter products, dietary supplements and any allergies or sensitivities. To cooperate with doctors and staff during your visit; and participate in your healthcare at the facility.
• To seek clarification when necessary to fully understand your health problems and proposed plan of action.
• To make known to your physician, caregiver, and surgery facility, any advance directives, or religious/cultural beliefs to be honored. o However, the facility WILL NOT honor a DNR (Do Not Resuscitate). In an emergency, we will act to employ all life saving measures while you are under our care.
• To follow the treatment plan and participate in the plan of care as ordered by the physician responsible for care. The consequences of non-compliance or refusal of recommended treatment and instruction rest with them.
• To follow rules and regulations affecting patient care, confidentiality, conduct and safety. To report any perceived safety issue to any staff member.
• To be considerate of the rights of others. To be respectful of all health care providers and staff, as well as other patients.
• To provide information for insurance claims and for working with our business office to make payment arrangements when necessary.
• To accept personal financial responsibility for any charges not covered by his/her insurance.
• To provide a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours if required by his/her provider.

This facility does not provide after-hours care, or emergency care.

Grievance Filing Contact Information:
Center: Administrator (269) 979-2490
State: Department of Licensing and Regulatory Affairs (800) 882-6006 Po box 30664/ Lansing, MI 48909
Federal: www.cms.hhs.gov/center/ombudsman.asp

(800) 633-4227

Estimate, Billing, and Payment Expectations

Billing Team

As a courtesy to our patients, a member of our billing team will contact your insurance company and provide you with information concerning any deductibles, co-payments or coinsurances that you may be responsible for “out-of-pocket”. We encourage you to contact your insurance company as well to review your insurance benefits.

Your Cost Estimate

Based on the information given to us by your insurance company, we will be contacting you by telephone, text, or e-mail with your anticipated facility out of picket costs. This figure includes co-pays, co-insurance and/or deductibles. Your insurance carrier will determine the final payment amount.

In the event that an additional procedure, testing, or services are provided the day of your surgical procedure, you may be responsible for additional patient charges (after insurance) if applicable.

Payment Expectations

We request that you pay your out-of-pocket expenses on the day of surgery. A member of the billing team will contact you by e-mail, text or by phone prior to the date of surgery with your anticipated out-of-pocket obligation. We accept cash, cheques, and most major credit cards. If you have not received a notification from the billing team at least three days prior to your surgery, please call Brookside Surgery Center at 260-979-2490. Failure to make prior financial arrangements may result in your surgery being postponed.

Billing

You may receive more than one bill for your surgical experience at Brookside Surgery Center. The surgery center bill reflects the facility charges only; you may receive separate bills from the surgeon and the anesthesia provider.

PLEASE REMEMBER TO BRING YOUR DRIVERS LICENSE AND INSURANCE CARDS WITH YOU.

Physician Owners