Ambulatory Surgery Center Policies

Notice of Privacy Practices

Policy on Advanced Directives

Most procedures done in an ASC setting are considered to be of minimal risk. If an adverse effect occurs during your treatment at this facility, all means of resuscitation or stabilizing measures will be performed and you will be transferred to an acute care hospital for further evaluation.

At the acute care hospital, further treatment or the withdrawal of treatment will be ordered in accordance with your wishes, advance directive, or health care Power of Attorney.

• You can provide the facility with a copy of your advanced directive / living will / health care proxy.
• The Facility does not honor this document
• I agree to proceed with the proposed procedure as scheduled.
• The facility can provide information on how I can obtain an advanced directive / living will / health care proxy.For Florida's regulations on advance directives and advance directive forms, please click here.

The Submission Process and Handling of Grievances

You have the right to voice any grievances regarding your treatment or care. You can file a grievance with the facility’s appointed representative by calling (941) 379-5884 or through the Office of the Medicare Beneficiary Ombudsman by visiting www.medicare.gov.

Recognizing the need for patients to understand what is expected regarding payment of medical services, we have established our financial policy. Some of these items are required by law.

• We will help you with the insurance process. We may call you before the procedure regarding your insurance coverage.
• You will be asked to sign an “assignment of benefits” form so that the payment comes directly to our Center. Your co-pay, deductibles, or co-insurance will be collected at the time of admission.
• A more personalized, written estimate of charges and other information will be provided to patients and prospective patients upon request from this facility. Patients and prospective patients should contact each health care practitioner who will provide services in the Ambulatory Surgery Center (ASC) to determine the health insurers and health maintenance organizations with which the health care practitioner participates as a network provider or preferred provider.
• If you have any questions regarding insurance coverage and pre-approval requirements, please call our Business Office at (941) 379-5884.
• Services may be provided in this health care facility by the facility as well as by other health care providers who may separately bill the patient and who may or may not participate with the same health insurers or health maintenance organizations as the facility.
• If your doctor should change the scheduled procedure or perform additional procedures, you may be responsible for additional payment.
• All co-pays and co-insurance required by your insurance company must be paid at the time services are rendered. We do not offer any payment plans. We accept cash, checks, Visa, MasterCard, Discover and "pre-approved" Care Credit accounts.
• It is the patient’s responsibility to be aware of the contract benefits of his/her insurance carrier. If your insurance requires referrals/pre-authorization for full benefits to be paid, it is your responsibility to verify that the referrals/pre-authorizations are in place prior to your visit.
• Our facility will file both primary and secondary insurance claims for medical services rendered. Claims for a third insurance contract will not be filed.
• We cannot file claims correctly without accurate information from you. Proof of insurance must be presented at each visit.
• If you do not have insurance, payment in full is expected at the time of service.
• To review quality/cost information about ambulatory surgery centers disseminated by the Agency for Health Care Administration (AHCA), click here: www.Floridahealthfinder.gov
• You will receive a statement from our office within 30 days of your insurance company’s response. If you are dissatisfied with their payment, please contact your insurance carrier. Payment of the patient’s portion of the balance is due upon receipt of the statement.
• We are participating providers for Medicare. This means that we must accept Medicare’s allowed charge for the services rendered. Medicare will pay 80% of the approved amount. The patient is responsible for the remaining 20% plus any out-of-pocket deductibles. We will write off the difference between what we charge and what Medicare approves. If you have secondary insurance, we will submit the claim for the remaining balance after Medicare has paid. Please remember that although we accept assignment for Medicare, the patient by federal law must be held responsible for any portion of the approved amount not paid by Medicare or a secondary insurance company.
• Responsibility for payment for services rendered to the child/children of divorced or separated parents rests with the parent who seeks treatment. Any court ordered judgment must be between the individuals involved, without including our facility.
• All accounts that are 60 days or more past due may be turned over to a collection agency.
• In the unlikely event your payment is returned unpaid, we may elect to re-present your payment to your financial institution up to two more times.

It is our hope that you will find this information helpful. If you have questions, please speak with our billing staff at (941) 379-5884.

SUBJECT:    

NONDISCRIMINATION, ACCESSIBILITY, LANGUAGE ACCESS AND REASONABLE MODIFICATION

POLICY:

The Center complies with Section 1557 of the Affordable Care Act[i] and the updated Section 504 regulations in 45 CFR Part 84[ii]. The Center ensures that all individuals can access services free from discrimination and free from accessibility barriers in delivery of care, communication, digital platforms, and medical diagnostic equipment.

The Center does not exclude, deny benefits to, or discriminate against any person on the basis of race, color, national origin, age, disability and sex, including discrimination based on pregnancy, gender identity and sex stereotyping.

The Center ensures accessibility in physical spaces, diagnostic equipment (if applicable), communication methods, and digital systems. Accessibility extends beyond physical access and includes how care is delivered, communicated, documented, and monitored throughout the organization.

Centers with 15 or more employees will appoint a Civil Rights Coordinator responsible for nondiscrimination, accessibility, grievance management, and Section 504 compliance.

All employees, providers and contracted personnel must conduct themselves in ways that ensure an environment free from discrimination and free from accessibility barriers. Staff receive initial and ongoing training regarding nondiscrimination, accessibility, effective communication, digital accessibility, and reasonable modifications.

PROCEDURE:

The Center will provide the notices of nondiscrimination and taglines:

• On an annual basis unless patient has opted out of receipt of notice
• Upon request
• In a conspicuous location on the ASC’s website
• In clear and prominent physical locations, in no smaller than 20-point sans serif font, where it is reasonable to expect individuals seeking service will be able to read or hear the notice
• In English and the top 15 non-English languages spoken in the state[iii].

The Center may elect to utilize the resources provided by the Office of Civil Rights (OCR).

Civil Rights for Providers of Health Care and Human Services | HHS.gov

The following resource provides a list of the top 15 non-English languages by State.

https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Appendix-A-Top-15.pdf

Notice of Nondiscrimination

The notice must include:

1. A statement the Center does not discriminate on the basis of race, color, national origin, sex, age or disability.
2. A statement the Center provides appropriate auxiliary aids and services, free of charge and in a timely manner, to individuals with disabilities.
3. A statement the Center provides language assistance services, free of charge and in a timely manner, to individuals with Limited English Proficiency (LEP).
4. How to obtain these aids and services.
5. Contact information for the designated Civil Rights Coordinator.
6. The availability of the grievance policy and procedure, including how to file a grievance.
7. How to file a discrimination complaint with the Office of Civil Rights.

Language Access

The Center provides:

1. Qualified interpreters
2. Translation of vital documents
3. Taglines in English and the top two non-English languages on small publications
4. No cost language assistance in a timely and accurate manner

Digital Accessibility

The Center ensures accessibility of:

1. Patient portals
2. Websites
3. Online registration systems
4. Mobile applications

Digital platforms must meet Web Content Accessibility Guidelines (WCAG) 2.1 AA accessibility standards[iv].  Assistance will be provided to individuals who cannot independently use digital systems.

Accessible Medical Diagnostic Equipment

The Center complies with updated Section 504 requirements for accessible medical diagnostic equipment. The Center will:

1. Maintain at least one accessible examination table, if examination tables are used.
2. Maintain at least one accessible weight scale, if weight scales are used.
3. Ensure at least 10% (or a minimum of one unit) of each type of MDE is accessible.
4. Ensure 20% accessibility threshold if the Center primarily serves patients with mobility disabilities.
5. Ensure all new MDE purchased, leased, or acquired after July 8, 2026, meet the required accessibility thresholds for accessible MDE.

Physical Accessibility

The Center maintains:

1. Accessible routes

2. Accessible restrooms

3. Accessible waiting areas

4. Accessible patient care areas

5. Access to diagnostic equipment is free from physical obstacles or workflow barriers

Physical obstacles identified by staff or patients must be addressed promptly.

Requests for Reasonable Modification

1. Requests may be made verbally or in writing
2. If a modification request can be provided immediately, staff will grant the modification and document it in the patient record.
3. If the modification is obvious and reasonable, staff may grant it without further dialogue and the modification will be noted in the patient’s record.
4. If the modification requested cannot be provided immediately, staff will notify the individual and forward the request to the Civil Rights Coordinator who will coordinate the determination.
5. The Center will acknowledge receipt of the request in writing within 4 business days and initiate a dialogue to assess the request.
6. The individual’s modification request must describe the needed modification and how it relates to their disability unless this is apparent or otherwise known.
7. If the disability or need is unclear, the Center may request documentation from a medical professional, a peer support group, a non-medical agency or a reliable third party who is knowledgeable about the patient’s disability and need for the requested modification.
8. The requester will be notified of any additional information needed and given a reasonable time for receipt of the requested information. If the requested information is not received in the allotted timeframe, the decision will be based upon the information available.
9. A final decision will be made within 7 business days. The decision will be communicated via telephone, text or in writing to the requester.
10. If a modification cannot be made because it will fundamentally alter the nature of the service, the Center will issue a written explanation and offer alternative modifications when possible.
11. The outcome of the decision to grant or deny the requested modification will be documented in the patient record.

Monitoring and Compliance

The Center conducts:

1. Quarterly accessibility audits
2. Annual digital accessibility reviews
3. Annual review of MDE accessibility thresholds
4. Staff competency assessments
5. Documentation audits for communication and modification requests

Findings are reported to the Governing Body.

Grievance Procedure

The Civil Rights Coordinator will:

1. Investigate all grievances
2. Document findings
3. Implement corrective actions
4. Communicate outcomes to the individual
5. Report findings to the Governing Body

[i] 42 U.S.C. § 18116 – Section 1557 of the Affordable Care Act.

[ii] 45 CFR Part 84 – Section 504 of the Rehabilitation Act (2024 updates).

[iii] CMS Appendix A – Top 15 Non‑English Languages by State.

[iv] Web Content Accessibility Guidelines (WCAG) 2.1 AA – Required digital accessibility standard under Section 504 and Section 1557.

The staff of this health care facility recognizes you have rights while a patient receiving medical care. In return, there are responsibilities for certain behavior on your part as the patient. This statement of rights and responsbilities is posted in our facility in at least one location that is used by all patients.

Your rights and responsibilities include:

A patient, patient representative or surrogate has the right to:

• Receive information about rights, patient conduct and responsbilities in a language and manner the patient, patient representative or surrogate can understand.
• Be treated with respect, consideration and dignity.
• Be provided appropriate personal privacy.
• Have disclosures and records treated confidentially and be given the opportunity to approve or refuse record release except when release is required by law.
• Be given the opportunity to participate in decisions involving their health care, excerpt when such participation is contraindicated for medical reasons.
• Receive care in a safe setting.
• Be free from all forms of abuse, neglect or harrassment.
• Exercise his or her rights without being subject to discrimination or reprisal with impartial access to medical treatment or accommodation, regardless or race, national origin, religion, physical disability, or source of payment.
• Voice complaints and grievances, without reprisal.
• Be provided, to the degree known, complete information concerning diagnosis, evaluation, treatment and know who is providing services and who is responsible for the care. When the patient's medical condition makes it inadvisable or impossible, the information is provided to a person designated by the patient or to a legally authorized person.
• Exercise of rights and respect for property and persons, including the right to:
  • Voice grievances regarding treatment or care that is (or fails to be) furnished.
  • Be fully informed about a treatment or procedure and the expected outcome before it is performed.
  • Have a persona appointed under State law to act on the patient's behalf if the patient is adjudged incompetent under applicable State health and safety laws by a court of proper jurisdiction. If a State court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with State law may exercise the patient's rights to the extent allowed by State law.
• Refuse treatment to extent permitted by law and be informed of medical consequences of this action.
• Know if medical treatment is for purposes of experimental research and to give his consent or refusal to participate in such experimental research.
• Have the right to change providers if other providers are available.
• A prompt and reasonable response to questions and requests.
• Know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
• Receive, upon request, prior to treatment, a reasonable estimate of charges for medical care and know, upon request and prior to treatment, whether the facility accepts the Medicare assignment rate.
• Receive a copy of a reasonable clear and understandable, itemized bill and, upon request, to have charges explained.
• Formulate advance directives and to appoint a surrogate to make health care decisions on his/her behalf to the extent permitted by law and provide a copy to the facility for placement in his/her medical record.
• Know the facility policy on advance directives.
• Be informed of the names of physicians who have ownership in the facility.
• Have properly credentialed and qualified healthcare professionals providing patient care.

A patient, patient representative or surrogate is responsible for:

• Providing a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, unless specifically exempted from this responsibility by his/her provider.
• Providing to the best of his or her knowledge, accurate and complete information about his/her health, present complaints, past illnesses, hospitalizations, any medications, including over-the-counter products and dietary supplements, any allergies or sensitivities, and other matters relating to his or her health.
• Accept personal financial responsibility for any charges not covered by his/her insurance.
• Following the treatment plan recommended by his health care provider.
• Be respectful of all the health providers and staff, as well as other patients.
• Providing a copy of information that you desire us to know about a durable power of attorney, health care surrogate, or other advance directive.
• His/her actions if he/she refuses treatment or does not follow the health care provider's instructions.
• Reporting unexpected changes in his or her condition to the health care provider.
• Reporting to his/her health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
• Keeping appointments.

Complaints

Please contact us if you have a question or concern about your rights or responsibilities.  You can ask any of our staff to help you contact the Administrative Director at the surgery center. Or, you can call:

941-379-5884.

We want to provide you with excellent service, including answering your questions and responding to your concerns.

You may also choose to contact the licensing agency of the state:

• Agency for Health Care Administration
• 2727 Mahan Drive
• Tallahassee, FL 32308
• 1-888-419-3456

If you are covered by Medicare, you may choose to contact the Medicare Ombudsman at 1-800-MEDICARE (1-800-633-4227) or online at

https://www.cms.gov/center/special-topic/ombudsman/medicare-beneficiary-ombudsman-home

The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive the information and help you need to understand your Medicare options and to apply your Medicare rights and protections.

In accordance with health and safety codes, the center and medical staff have adopted the following:

Patient and Patient/Guardian have the right:

1. To care and services without regard to sex or culture, economic, educational, or religious background or the source of payment for your child's care.
2. For considerate and respectful care.
3. To know the name of the physician who has primary responsibility for coordinating your child's care adn the names and professional relationships of other physicians who will see your child.
4. For the parent/guardian to receive information from the child's physician about the child's illness, his or her course of treatment and his or her prospects for recovery in easy to understand terminology.
5. For the parent/guardian to receive as much information about any proposed treatment or procedure as he/she may need in order to give informed consent or to refuse this course of treatment. Except in emergencies, the information shall include a description of the procedure or treatment, the medically significant risks involved and knowledge of the name of the person who will carry out the procedure or treatment.
6. For the parent/guardian to participate actively in decisions regarding the child's medical care. To the extent permitted by law, including the right of theparent/guardian to refuse treatment. the child will be included in all decisions as much as possible dependent on their age and developmental state.
7. Full consideration of privacy concerning the child's medical care programs. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. The parent/guardian has the right to know the reason for the presence of any individual.
8. To confidential treatment of all communications and records pertaining to the child and their care stay in the Center. The written permission of the parent/guardian shall be obtained before the child's medical records can be made available to anyone not directly concerned with their care.
9. To reasonable responses to reasonable requests that the parent/guardian or child may make for services including: (a) explaining to the child that is it all right to be afraid and it is okay to cry; (b) keeping the child with parents as much as possible within the written policy and guidelines of the Center; and (c) allow the child to keep a favorite toy, blanket or the like with them at all times as appropriate.
10. For the parent/guardian to leave the Center with child prior to the procedure and/or against the advice of the child's physicians. The Center will follow all State and Federal laws with regards to reporting suspected neglect or abuse.
11. To reasonable continuity of care and to know in advance the time and location of appointment as well as the physician providing the care.
12. To be advised if the Center/personal physician proposes to engage in or perform human experimentation affecting the child's care or treatment. The parent/guardian has the right to refuse to participate in any such research projects.
13. To be informed by your child's physician or a delegate of the physician of their continuing health care requirements following discharge from the Center.
14. To file a complaint with the Department of Health during normal work hours if you have concerns about the care being provided in this licensed ambulatory surgery center. You may also wish to discuss you concerns with the Administrative Director for this facility.

FAMILY RESPSONSIBILITY

Parents/family shall have the responsibility for;

1. Continuing their parenting role to the extent of their ability.
2. Being available to participate in decision-making and providing staff with knowledge of parents/guardian whereabouts.
3. Pre-operatively receive information from the physician an explanation of the procedure, associated alternative treatment, the risks, and projected outcome of surgical procedure.
4. Full consideration of privacy concerning the child's medical care. Case discussion, consultation, examination, and treatment are confidential and should be conducted discreetly. Parent/guardian has the right to know the reason for the presence of any individual.
5. Be advised if your child's physician proposes to engage in or perform human experimentation affecting your child's treatment.

NOTE:  A family consists of those individuals responsible for physical and emotional care of the child on a continuous basis regardless of whether they are related.

Complaints

Please contact us if you have a question or concern about your rights or responsibilities.  You can ask any of our staff to help you contact the Administrative Director at the surgery center. Or, you can call:

941-379-5884.

We want to provide you with excellent service, including answering your questions and responding to your concerns.

You may also choose to contact the licensing agency of the state:

• Agency for Health Care Administration
• 2727 Mahan Drive
• Tallahassee, FL 32308
• 1-888-419-3456

If you are covered by Medicare, you may choose to contact the Medicare Ombudsman at 1-800-MEDICARE (1-800-633-4227) or online at

https://www.cms.gov/center/special-topic/ombudsman/medicare-beneficiary-ombudsman-home

The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive the information and help you need to understand your Medicare options and to apply your Medicare rights and protections.