docWELCOME to The Surgery Center at Lutheran
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WELCOME to The Surgery Center at Lutheran
WELCOME to The Surgery Center at Lutheran We are delighted that you have chosen to have your surgery or procedure at our facility. Our goal is to make your visit and recovery a positive experience. We offer a comfortable, welcoming facility with a highly-skilled, caring, friendly staff. The staff teams with your doctor to give you the best care through use of state-of-the-art medical equipment and the latest innovations in surgery procedures and technology. Please review the instructions contained in this packet to help you prepare for your surgery. BEFORE your visit to The Surgery Center at Lutheran Our pre-op nurse will contact you to complete your confidential and mandatory health history. This is required prior to your surgery date to avoid cancellation of your surgery. If it is more convenient you may contact the pre-op nurse by calling 303-301-7708. Please arrange for a responsible adult to drive you home from the Surgery Center and to listen to your post-operative instructions. If you are receiving any sedation and/or anesthesia someone must stay with you for 24 hours after your surgery/procedure. SCHEDULING CONFIRMATION Date of Surgery: ___________________ Time of Arrival: ____________________ Special Instructions: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Instructions for THE DAY OF SURGERY Arrive promptly at the time given to you by the pre-op nurse. Bring all the surgical paperwork you were given in the surgeon’s office. Follow the instructions given to you about eating and drinking. This is important for your safety. Shower the morning of surgery — this will decrease the risk of infection. Wear low-heeled shoes and loose, comfortable clothing. Sleeves, legs and waistbands should be loose enough to fit over bandages. All jewelry and body piercing must be removed prior to surgery. Please leave valuables including jewelry at home or with a family member. Bring your driver’s license or photo identification card and health insurance cards, as well as any co-pay and/or deductible to be paid at registration. Leave valuables at home or with your friends/family. Medications - You may take your normal heart, blood pressure, breathing or seizure medication the morning of surgery with a sip of water. -if you take insulin or routine medications, your doctor or anesthesiologist will instruct you on what to take prior to surgery. - if you are on blood thinners, aspirin or herbal medicines, notify your surgeon when they are scheduling you for surgery -Please be sure to tell your surgeon about any existing medical conditions as well as prescription, herbal and over the counter medications that you are taking. Failure to follow these instructions can cause serious complications. Instructions for AFTER YOUR SURGERY After your surgery/procedure you will receive care in the “Post Anesthesia Care Unit” where the nurses will watch you closely until you are ready to be put in a recliner. Once in the recliner, one family member may join you. In most cases, depending on your procedure, you will be ready to leave the Center in 30 minutes to 2 hours following completion of your surgery. Before you are discharged, your nurse will review your home care instructions with you and your family. A copy of these instructions will be sent home with you. Have someone stay with you for the first 24 hours after surgery. Take it easy until your physician says you can return to your normal routine. It is natural to experience some discomfort in the area of the operation. You may also experience some drowsiness or dizziness depending on the type of anesthesia you receive or on the amount of pain medication you are taking at home. Do not drive, operate heavy machinery or power tools, cook, drink alcoholic beverages, smoke, make legal decisions, or take any medications not prescribed by your physician for at least 24 hours after your surgery. The day after surgery, a member of the Surgery Center staff will call to see how you are feeling. Contact your physician if you feel you are having problems after surgery. If you cannot contact your doctor but feel your concerns warrant a doctor’s attention, call or go to the emergency room closest to you. The Surgery Center at Lutheran HIPAA 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 carefully. The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal law governing the privacy of individually identifiable health information. We are required by HIPAA to notify you of the availability of our Notice of Privacy Practices. This notice describes our privacy practices, legal duties and your rights concerning your Protected Health Information (PHI) and includes provisions outlined in the 2013 HIPAA Final Omnibus Rule. Your Protected Health Information We may collect, use and share your PHI for the following reasons: For payment: We use and share PHI to manage your account or benefits and to obtain reimbursement for the health care services we provide. For health care operations: We use and share PHI for our health care operations. For example, we may use PHI to review the quality of care and services you receive. For treatment activities: We use and share PHI to ensure you receive the treatment you need. To you: We must give you access to your own PHI. We may send you reminders about required follow-up care. To others: You may tell us in writing that it is okay for us to give your PHI to someone else for any reason. Also, if you are present and tell us it is okay, we may give your PHI to a family member, friend or other person. We would do this if it has to do with your current treatment or payment for your treatment. If you are not present, if it is an emergency, or you are not able to tell us it is okay, we may give your PHI to a family member, friend or other person if sharing your PHI is in your best interest. As allowed or required by law: We may also share your PHI, as allowed by federal law, for many types of activities. PHI can be shared for health oversight activities. It can also be shared for judicial or administrative proceedings, with public health authorities, for law enforcement reasons, and with coroners, funeral directors or medical examiners (about decedents). PHI can also be shared with organ donation groups for certain reasons, for research, and to avoid a serious threat to health or safety. It can be shared for special government functions, for Workers' Compensation, to respond to requests from the U.S. Department of Health and Human Services, and to alert proper authorities if we reasonably believe you may be a victim of abuse, neglect, domestic violence or other crimes. PHI can also be used to report certain information to the U.S. Food & Drug Administration about medical devices that break or malfunction. Authorization: We will obtain permission from you in writing before we use or share your PHI for any other purpose not stated in this notice. You may withdraw your authorization, in writing, at any time. We will then stop using your PHI for that purpose. If we have already used or shared your PHI based on your authorization, we cannot undo any actions we took before you told us to stop. How We Protect Information We are dedicated to protecting your PHI and have set up a number of policies and practices to make sure your PHI is kept secure. We keep your oral, written and electronic PHI safe using physical, electronic and procedural means. These safeguards follow federal and state laws. Some of the ways we keep your PHI safe include securing offices that hold PHI, passwordprotecting computers, and locking storage areas and filing cabinets. We require our employees to protect PHI through written policies and procedures. These policies limit access to PHI to only those employees who need the data to perform their job. Employees are also required to wear ID badges to help keep people who do not belong out of areas where sensitive data is kept. Your Rights: You may: Receive a copy of this Notice of Privacy Practices Request limits on disclosure of your PHI Receive access to view some or all of your medical record Receive a paper or electronic copy of your medical record within 30 days of your documented request Request an amendment to your PHI Expect your record to be amended within 60 days of your request Restrict disclosure of PHI to a health plan when you pay in full at the time of service Receive a record of how we have used and/or shared your health information Receive information on how to file a complaint if you feel your privacy has been violated Opt out of fundraising efforts (when applicable) We will: Not sell your PHI Notify you in the event of a breach of your PHI Contact for further information concerning our privacy practices: You may contact the Privacy Officer at (303) 301-7700. Complaints: If you think we have not protected your privacy, you can file a complaint with us. You may also file a complaint with the Office for Civil Rights in the U.S. Department of Health & Human Services. We will not take action against you for filing a complaint. Rev. 09/2013 The Surgery Center at Lutheran HIPAA Notificación de Privacidad Esta notificación describe como información médica sobre usted puede ser utilizada y como puede usted puede tener acceso a esa información. Por favor lea cuidadosamente. La Ley de Portabilidad y Responsabilidad del Seguro de Salud de 1996 (HIPAA) es una ley federal que regula la privacidad de la información médica personal. Estamos obligados por la ley HIPAA para notificarle de la disponibilidad de nuestro Aviso de Prácticas de Privacidad. Este aviso describe nuestras prácticas de privacidad, derechos legales y sus derechos con respecto a su información médica protegida (PHI), e incluye disposiciones que se expresan en las reglas establecidas en el 2013 de HIPAA. Protección de su información medica Podemos juntar, usar y compartir su información médica (PHI) por las siguientes razones: Para pagos: Usamos y compartimos su PHI para manejar su cuenta o beneficios y para obtener el reembolso por los cuidados proveídos. Para operaciones de cuidados médicos: Usamos y compartimos su PHI para operaciones de cuidados médicos. Por ejemplo, para revisar la calidad de atenciones y servicios que usted recibe. Para actividades de tratamiento: Usamos y compartimos su PHI para asegurarnos que usted recibe el tratamiento que usted necesita. Para usted: Nosotros debemos darle a usted su propia PHI. Así podemos mandar recordatorios sobre atenciones de seguimiento requeridas. Para otros: Usted puede decirnos por escrito que está bien para nosotros dar su PHI a otra persona por cualquier motivo. Además, si usted está presente y nos dice que está bien, podemos dar su PHI a un familiar, amigo u otra persona. Queremos hacer esto si tiene que ver con su tratamiento o pago por su tratamiento actual. Si usted no está presente, si se trata de una emergencia, o que no son capaces de decirnos que está bien, es posible que demos su PHI a un familiar, amigo u otra persona si comparte su PHI está en su mejor interés. Según lo permitido o requerido por ley: También podemos compartir su PHI, según lo permitido por la ley federal, para muchos tipos de actividades. Su PHI puede ser compartida para actividades de supervisión de la salud. También puede ser compartida por procedimientos judiciales o administrativos, con las autoridades de salud pública, por razones de orden público, y con médicos forenses, directores de funerarias o médicos forenses (alrededor de los difuntos). Su PHI también puede ser compartida con los grupos de donación de órganos, por ciertas razones, para la investigación, y para evitar una amenaza grave a la salud o la seguridad. Puede compartirse para funciones especiales del gobierno, para la indemnización de los trabajadores, para responder a las solicitudes del Departamento de Salud y Servicios Humanos de los EE.UU., y para alertar a las autoridades correspondientes si tenemos razones para creer que puede ser víctima de abuso, negligencia, violencia doméstica u otros delitos. Su PHI también puede ser usado para reportar cierta información a la Food & Drug Administration de EE.UU. acerca de los dispositivos médicos que se rompen o mal funcionamiento. Autorización: Vamos a obtener el permiso de usted por escrito antes de usar o compartir su PHI para cualquier otro propósito no especificado en este aviso. Usted puede retirar su autorización, por escrito, en cualquier momento. A continuación, se deja de usar su PHI para ese propósito. Si ya hemos utilizado o compartido su PHI en base a su autorización, no podemos deshacer cualquier acción que tomamos antes de que usted nos haya dicho que se detuviera. Cómo protegemos su información: Estamos dedicados a proteger su PHI y han establecido una serie de políticas y prácticas para asegurar que su PHI se mantenga segura. seguridad siguen las leyes federales y estatales. Algunas de las formas en las que guardar su caja fuerte PHI incluyen oficinas de fijación que sujetan PHI, ordenadores para proteger con contraseña y bloqueo de las áreas de almacenamiento y archivadores. Exigimos a nuestros empleados proteger su PHI a través de políticas y procedimientos escritos. Estas políticas limitan el acceso a la PHI sólo a aquellos empleados que necesitan la información para realizar su trabajo. También se requiere que los empleados usen tarjetas de identificación para ayudar a mantener a las personas que no pertenecen a las áreas donde se guarda la información confidencial. Sus Derechos: Usted puede: Recibir una copia de esta notificación de privacidad Solicitar límites a la divulgación de su PHI Recibir acceso a parte o todo su historial medico Recibir una copia de su historial médico en papel o una copia electrónico dentro de 30 días de recibir su petición Solicitar una modificación a su PHI Esperar su modificación dentro de 60 días Restringir la divulgación de su PHI a un plan de salud cuando usted paga en su totalidad en el momento del servicio Recibir un registro de cómo se ha utilizado y / o compartido su información de salud Recibir información sobre cómo presentar una queja si usted cree que su privacidad ha sido violada Optar fuera de esfuerzos de recaudación de fondos (cuando corresponda) Nosotros: No venderemos su PHI Le notificaremos en caso de una violación de su PHI Mantenemos su PHI oral, escrita y electrónicamente segura utilizando medios físicos, electrónicos y de procedimiento. Estas medidas de Llámenos para más información sobre las prácticas de privacidad. Puede comunicarse con el Director de Privacidad al (303) 301-7700. Quejas: Si usted cree que su privacidad no ha sido protegida, usted puede presentar una queja con nosotros. También puede presentar una queja con la Oficina de Derechos Civiles con el Departamento de Salud y Recursos Humanos de los E.E.U.U. No tomaremos medidas en su contra por presentar una queja. Rev. 09/2013 THE SURGERY CENTER AT LUTHERAN PATIENT’S RIGHTS AND RESPONSIBILITIES Each patient treated at this Ambulatory Surgery Center, or their representative, has the right to: Be treated with respect, consideration, and dignity. Respectful care given by competent personnel with consideration of their privacy concerning their medical care. Be given the name of their attending physician, the names of all other physicians directly assisting in their care, and the names and functions of other health care persons having direct contact with the patient. Have records pertaining to their medical care treated as confidential. Know what surgery center rules and regulations apply to their conduct as a patient. Expect emergency procedures to be implemented without necessary delay. Absence of clinically unnecessary diagnostic or therapeutic procedures. Expedient and professional transfer to another facility when medically necessary and to have the responsible person and the facility that the patient is transferred to notified prior to transfer. Treatment that is consistent with clinical impression or working diagnosis. Good quality care and high professional standards that are continually maintained and reviewed. An increased likelihood of desired health outcomes. Full information in layman’s terms concerning appropriate and timely diagnosis, treatment, and preventive measures; if it is not medically advisable to provide this information to the patient, the information shall be given to the responsible person on his/her behalf. Receive a second opinion concerning the proposed surgical procedure, if requested. Accessible and available health services; information on after-hour and emergency care. Give an informed consent to the physician prior to the start of a procedure. Be advised of participation in a medical care research program or donor program; the patient shall give consent prior to participation in such a program; A patient may also refuse to continue in a program that has previously given informed consent to participate in. Receive appropriate and timely follow-up information of abnormal findings and tests. Receive appropriate and timely referrals and consultation. Receive information regarding “continuity of care” Refuse drugs or procedures and have a physician explain the medical consequences of the drugs or procedures. Appropriate specialty consultative services made available by prior arrangement. Medical and nursing services without discrimination based upon age, race, color, religion, gender, sexual orientation, national origin, handicap, disability, or source of payment. Have access to an interpreter whenever possible. Be provided with, upon request, access to information contained in their medical record. Accurate information regarding the competence and capabilities of the organization, its employees, and medical staff. Receive information regarding methods of expressing suggestions or grievances to the organization. Appropriate information regarding the absence of malpractice insurance coverage. Change primary or specialty physicians or dentists if other qualified physicians or dentists are available. Health services provided are consistent with current professional knowledge. Appropriate assessment and management of pain. Participate in their own healthcare decisions except if this is contraindicated due to medical reasons. Receive a Patient Privacy Notice which provides an explanation of how their protected health information is utilized and to those that may need to receive it. (Notification if a breach of unsecured health information occurs.) Pastoral and/ or spiritual support Each patient treated at this facility has the responsibility to: Provide full cooperation with regards to instructions given by his/her surgeon, anesthesiologist, and operative care (pre and post). Provide the surgery center staff with all medical information which may have a direct effect on the provider at the surgery center. Provide the surgery center with all information regarding third-party insurance coverage. Know their insurance requirements, such as pre-authorization, deductibles and co-payments Fulfill financial responsibility, for all services received, as determined by the patient’s insurance carrier. Act in respectful and considerate manner toward healthcare providers, other patients and visitors. * See back cover for important phone numbers Grievance Process You and your representative have the right to: Voice a complaint to your healthcare providers and administrators without a fear of reprisal. Contact the Management Representative at 303-301-7700 to file a formal grievance. Or, you may contact the State of Colorado to issue a grievance. Their website is: http://www.dora.state.co.us/medical/complaints.htm or call 303-894-7690. Contact the Colorado Department of Health and Human services @ 303-692-2800 0r 1-800-886-7689×2800 Contact the Medicare Hotline @ 1-800-633-4227 or http://www.medicare.gov/claims-and-appeals/medicare-rights/gethelp/ombudsman.html Contact the Accreditation Association of Ambulatory Health Care www.aaahc.org Receive a timely response with the results of your complaint (if issued to the Surgery Center directly). Unresolved complaints are directed to the facilities director within 3 days and are responded to in writing. Advance Directives You and your representative have the right to know that: Patients treated at The Surgery Center at Lutheran are expected to be in reasonably good health and of low surgical/procedure risk; making resuscitation appropriate for conditions of preserving life, until transfer to hospital occurs. Your advance directives will not prevent treatment of a life threatening condition should one occur while you are receiving care at The Surgery Center at Lutheran. In the event of a life threatening condition, you will be treated, stabilized and transferred via EMS to the closest appropriate acute care facility. Important Numbers & Websites: The Facility Administrator: 303-301-7702 State of Colorado: 303-894-7690 http://www.dora.state.co.us/medical/complaints.htm Colorado Department of Health and Human services: 303-692-2800 or 1-800-886-7689 x2800 Medicare Hotline: 1-800-633-4227 http://www.medicare.gov/claims-and-appeals/medicare- rights/gethelp/ombudsman.html PATIENTS RIGHTS AND RESPONSIBILITIES 3455 LUTHERAN PARKWAY SUITE 150 WHEAT RIDGE, CO 80033 303-301-7700 www.lutheranasc.com OWNERSHIP DISCLOSURE The physician who has referred you to The Surgery Center at Lutheran may have a limited investment in this facility and therefore may have a “significant beneficial interest” in referring you to us. You are free to choose another facility in which to receive the services that have been ordered by your physician. James Barron, MD B. Andrew Castro, MD William Ciccone, MD David Conyers, MD Cornerstone Wheat Ridge ASC, LLC Gayle Crawford, MD Tom Eickmann, MD Thomas Fry, MD Jennifer Grube, MD Michael Johnson, MD Robert Kawasaki, MD Erik Kreutzer, MD Nicholas Olsen, DO Matthew Paden, DPM William Saber, MD Brett Sachs, DPM Daniel Saunders, MD Gregory Still, DPM Michael Tralla, MD Christopher Wilson, MD Tracy Wolf, MD Fredric Zimmerman, DO The Surgery Center at Lutheran is a joint venture with Lutheran Medical Center / SCL Health DERECHOS Y RESPONSABILIDADES DE LOS PACIENTES 3455 LUTHERAN PARKWAY SUITE 150 WHEAT RIDGE, CO 80033 303-301-7700 Números de teléfono importantes: El Centro de Cirugía Luterano Administrador - 303-301-7702 Departamento de Salud y Servicios Humanos 303-692-2800 or 1-800-886-7689 x2800 Línea directa de Medicare: 1-800-633-4227 Website: www.cms.hhs.gov/center/ombudsman.asp Sitio Web: www.lutheranasc.com EL CENTRO DE CIRUGÍA LUTERANO DERECHOS DEL PACIENTE Y RESPONSABILIDADES Cada paciente tratado en este Centro de Cirugía Ambulatoria tiene el derecho de: Ser tratados con respeto, consideración y dignidad. Atención respetuosa por personal competente a la consideración de su privacidad sobre su atención médica. Saber el nombre de su médico tratante, los nombres de todos los demás médicos directamente en la ayudar de su cuidado, y las funciones de cada quien. Tienen los registros relativos a la atención médica en forma confidencial. Saber qué normas y reglamentos son aplicables a su conducta como un paciente. Que los procedimientos de emergencia deberán aplicarse sin demora necesaria. Falta de procedimientos clínicamente innecesaria diagnósticos o terapéuticos. Transferencia rápida y profesional a otro establecimiento cuando sea médicamente necesario y que la persona responsable y la planta que el paciente sea trasladado sea notificado antes de la transferencia. Tratamiento que es compatible con impresión clínica o diagnóstico en trabajo. Que se mantengan continuamente y revisado la atención de buena calidad y el alto nivel professional. Un aumento de la probabilidad de resultados deseados. Toda la información en términos más generales sobre diagnóstico, tratamiento y medidas preventivas; si no es médicamente adecuada y oportuna aconsejable para proporcionar esta información a la paciente, la información a la persona responsable en su nombre. Recibir una segunda opinión sobre la propuesta de procedimiento quirúrgico, si lo solicita. Accesibles y los servicios de salud; información sobre la hora y la atención de urgencia. Dar un consentimiento informado por parte del médico tratante antes del inicio de un procedimiento. Se informó de la participación en un programa de investigación sobre atención médica o programa de donantes; el paciente deberá dar su consentimiento antes de la participación en este tipo de Programa; Un paciente puede también negarse a continuar en un programa que ya ha dado su consentimiento informado para participar. Una adecuada y oportuna información de seguimiento de resultados anormales y pruebas. Recibir las remisiones y consulta adecuada y oportuna. Recibir información sobre la "continuidad de la atención" Niegan medicamentos o procedimientos y un médico explicar las consecuencias médicas de los medicamentos o procedimientos. Servicios de consultoría especializada adecuada asu disposición segun previo acuerdo. Servicios Médicos y de enfermería sin discriminación basada en edad, raza, color, religión , género, orientación sexual, origen nacional, discapacidad, discapacidad, o la fuente de pago. Tener acceso a un intérprete siempre que sea posible. Estar provistos en su caso, previa solicitud, el acceso a la información contenida en su expediente médico. Información precisa en relación con la competencia y la capacidad de la organización, sus empleados, y el personal médico. Recibir información sobre métodos para expresar sugerencias o quejas a la organización. Información adecuada en relación con la ausencia de la negligencia de su cobertura. Cambio principal o especialidad los médicos o dentistas si otros médicos o dentistas están disponibles. Servicios de salud prestados sean consistentes con los conocimientos profesionales. Una adecuada evaluación y manejo del dolor. Participar en sus propias decisiones de atención de la salud excepto si este está contraindicado debido a razones médicas. Recibir un paciente Aviso de privacidad que proporciona una explicación de cómo su información de salud protegida es utilizado y a los que necesitan recibir . Apoyo espiritural pastoral y/o Cada paciente tratado en este centro tiene la responsabilidad de: Proporcionar plena cooperación en lo que respecta a las instrucciones dadas por su cirujano, anestesiólogo, y cuidados postoperatorios (pre y post). Proporcionar al centro de cirugía personal con toda la información médica que puede tener un efecto directo sobre el proveedor de servicios en el centro de cirugía ambulatoria. El centro de cirugía ambulatoria con toda la información relativa a terceros cobertura de seguro. Conocer sus necesidades de seguros, como una pre-autorización, deducibles y co-pagos Cumplir con responsabilidad financiera, para todos los servicios recibidos, según lo determinado por el paciente portador de seguro. Actuar de forma respetuosa y considerada hacia los proveedores de servicios de salud, otros pacientes y visitantes. * Ver portada para números de teléfono importantes DECLARACIÓN DE PARTICIPACIÓN El médico que le ha recomendado al Centro de Cirugía Luterano puede tener una inversión limitada en este tipo de instalaciones y Por lo tanto, pueden tener una importante participación en los beneficios" en Refiriéndose a nosotros. Usted es libre de elegir otro servicio Para recibir los servicios que se han ordenado por El médico. Los médicos que forman parte los propietarios: James Barron, MD B. Andrew Castro, MD William Ciccone, MD David Conyers, MD Cornerstone Wheat Ridge ASC, LLC Gayle Crawford, MD Tom Eickmann, MD Thomas Fry, MD Jennifer Grube, MD William Hineser, DPM Michael Johnson, MD Robert Kawasaki, MD Erik Kreutzer, MD Nicholas Olsen, HACER Mateo Paden, DPM William Sable, MD Brett Sachs, DPM Daniel Saunders, MD Gregory Still, DPM Michael Tralla, MD Christopher Wilson, MD Tracy Wolf, MD Fredric Zimmerman, DO The Patient Self-Determination Act 3455 Lutheran Parkway Suite 150 Wheat Ridge, CO 80033 303-301-7700 www.lutheranasc.com T he Patient Self-determination Act is a federal law that requires hospitals to “provide written information” to adult inpatients concerning “an individual’s right under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives.” To help patients make these choices, Colorado law provides for advance directives. This brochure outlines what advance directives are and what Colorado statutes require. The Durable Power of Attorney for Health Care A form in which a person gives someone else the right to make decisions about their health care. This person is called an “agent.” An agent cannot be a physician or other health care provider, unless the health care provider is related by blood or marriage to the person signing the document. This document must also be notarized or signed by two witnesses. These witnesses must follow the same criteria as the Living Will. The Pre-Hospital “Do Not Resuscitate Request” Advance Directives Advance directives are papers that state a patient’s choices for treatment. This includes decisions like refusing treatment, being placed on life support, and stopping treatment at a point the patient chooses. It also includes requesting specific life sustaining treatments. There are several kinds of advance directives. The three that are most common are the living will; durable power of attorney for healthcare and the pre-hospital do not resuscitate order. The Living Will A form that states that life sustaining procedures should be withheld or withdrawn. This only goes into effect when the patient can no longer make decisions. Medical procedures which are necessary to provide comfort or pain relief are not considered life-sustaining procedures. For the Living Will to be effective, two physicians must personally examine the patient and determine that the patient has a terminal illness. The physicians must agree that death will occur with or without intervention. The living will must be notarized or signed by two witnesses. These witnesses must be two adults that are not involved with the patient’s care or financially responsible for the patient. A form that lets the patient prohibit medical procedures outside the hospital. The form must be signed by a doctor and given to emergency personnel if they are called. The Surgery Center at Lutheran will not discriminate against those patients who have or have not completed an Advance Directive. The Patient Self-Determination Act requires that all adult patients be provided with written information concerning the right to formulate an Advance Directive. All patients will be questioned as to the existence of an advance directive and provided with information if they so desire. For all Advance Directives to be effective, copies must be placed on the chart upon admission. If, for any reason the hospital or the physician cannot carry out the wishes of the Advance Directive, the patient will be transferred to another physician or hospital that is willing to follow the instructions. For further information please visit the website at: www.caringinfo.org/stateaddownload or 1-800-658-8898 or www.healthfacilites.info The Surgery Center at Lutheran respects your right to participate in decisions regarding your health care. Our policy is that we will use all measures possible to sustain life. Ley de auto-determinación del paciente 3455 Lutheran Parkway Suite 150 Wheat Ridge, CO 80033 303-301-7700 La ley de auto-determinación es ley federal que requiere que los hospitales "proporcionen información escrita" para adultos hospitalizados sobre el "derecho de la persona bajo la ley del estado para tomar decisiones relativas a la atención médica, incluyendo el derecho a aceptar o rechazar tratamientos médicos y quirúrgicos y el derecho a formular las directrices anticipadas." Para ayudar a los pacientes a tomar estas decisions la, ley de Colorado ofrece las directrices anticipadas. Este folleto describe lo que son las voluntades anticipadas y lo que los estatutos exigen en Colorado. El poder notarial duradero para la atención de la Salud Un formulario en la que una persona le da a otra persona el derecho de tomar decisiones sobre su atención médica. Esta persona se denomina como un "agente". Un agente no puede ser un médico u otro proveedor de atención médica, a menos que el médico se relaciona por sangre o matrimonio a la persona que firma el documento. Este documento debe ser firmado ante un notario o por dos testigos. Estos testigos deben seguir los mismos criterios que en la voluntad de vivir. Los primeros auxilios "Peticion de No Resucitar " Las Directivas avanzadas Las directrices anticipadas son documentos que indicant las opciones de tratamiento. Esto incluye la adopción de decisiones como denegación de tratamiento, apoyo a la vida, y la interrupción del tratamiento en el punto en el cual el paciente elige. También incluye solicitar mantener tratamientos específicos para mantenerse en vida. Hay varios tipos de directrices anticipadas. Los tres más comunes son la voluntad de vivir; poder notarial duradero para la atención de la salud y la orden de no resucitar. La voluntad de vivir Un formulario cual indica si deben ser suspendidos o retireados los procedimientos de sostenimiento de vida artificial. Esto sólo entra en vigor cuando el paciente ya no puede tomar decisiones. Los procedimientos médicos que son necesarios para proporcionar comodidad o alivio del dolor no se consideran procedimientos de conservación de la vida. Para que sea eficaz la voluntad devivir dos médicos deben interrogar personalmente al paciente y determinar que el paciente tiene una enfermedad terminal. Los médicos deben estar de acuerdo que la muerte se producirá con o sin intervención. La voluntad de vida debe ser notariada o firmada por dos testigos. Estos testigos deben ser dos adultos que no están relacionadas con el cuidado del paciente o financieramente responsable del paciente. Un formulario que permite al paciente prohibir los procedimientos médicos fuera del hospital. El formulario debe estar firmado por un médico y entregado al personal de emergencia en caso que sean llamados. Centro de Cirugía Luterano, no discrimina a aquellos pacientes que hayan o no hayan completado una directiva avanzada. La Ley de auto determinación del paciente requiere que todos los pacientes adultos reciban información escrita sobre el derecho a formular un directiva avanzada. Todos los pacientes deberán ser cuestionado en cuanto a la existencia de una directiva avanzada, o proporcionarles con la información si así lo desean. Par que todas las directivas avanzadas sean eficaces, las copias deben ser colocadas en el archive al ser ingresado. Si, por cualquier razón, el hospital o el médico no puede cumplir los deseos de la Directiva, el paciente va a ser trasladado a otro médico u hospital que está dispuesto a seguir las instrucciones. Para obtener más información, visite el sitio web en: www.caringinfo.org/stateaddownload o llame al 1-800-658-8898 o www.healthfacilites.info El Centro de Cirugía Luterano respeta su derecho a participar en las decisiones sobre su atención de la salud, nuestra política es que vamos a utilizar todas las medidas posibles para mantener la vida. The Surgery Center at Lutheran Conditions of Service / Consent for Treatment 1. The Surgery Center maintains personnel and facilities to assist your physician(s) in his or her performance of various surgical operations and other special diagnostic or therapeutic procedures and/or treatment. These procedures may all involve risks of unsuccessful results, complications, injury, or even death, from both known and unforeseen causes, and no warranty or guarantee is made as to result or cure. You have the right to be informed of such risks as well as the nature of the operation, procedure and/or treatment; the expected benefits or effects of the same; and the available alternative methods and their risks and benefits. Except in cases of emergency, operations, procedures and/or treatments are not performed until you have had the opportunity to receive this information and have given your consent. You have the right to consent or to refuse any proposed operation, procedure and/or treatment any time prior to its performance. 2. The operation, procedure and/or treatment will be performed by my physician (or in the event of an emergency causing his or her inability to complete the procedure, a qualified substitute physician or surgeon), together with associates and assistants, including anesthesiologists, pathologists, and radiologists from the medical staff to whom the physician or surgeon may assign designated responsibilities. The person in attendance for the purpose of performing specialized medical services such as anesthesia, radiology, or pathology are not agents, servants, or employees of the Center or your physician or surgeon, but are independent contractors and, therefore, your agents, servants, or employees. 3. The pathologist is hereby authorized to use his or her discretion in disposing of any member, organ, or other tissue removed from your person during the operations or procedures set forth above. 4. Advance Directives: I understand that even though the physicians and staff of the Surgery Center respect my rights to participate in decisions regarding my health care, the policy of the Surgery Center is that all patients undergoing surgical procedures will be considered eligible for life-sustaining emergency treatments. 5. In the event of an emergency or urgent situation: I consent to the transfer and/or admission to a nearby acute-care facility for continuity of care. In the case of an emergency transfer to another facility or hospital, I consent to the use of blood and/or blood by-products at the receiving facility. (Initial on the appropriate line) _______Yes, I agree to a blood transfusion if needed in an emergency. _______ No, I refuse a blood transfusion even in an emergency. In the Case of an Emergency: Notify my next of kin: Name: ______________________________ Phone: _________________ 6. Accidental Exposure: In the event of an accidental exposure of my blood or bodily fluids to a physician, contractor, or employee of the facility, I consent to testing for HIV and Hepatitis. 7. Health Plan Obligation: This Center maintains a list of health plans with which it contracts. A list of such plans is available upon request from the Administrative Office of this Center. The Center has no contract, expressed or implied, with any health plan that does not appear on the list. The undersigned agrees that she/he is individually obligated to pay the full charges of all services rendered to him/her if he/she belongs to a plan that does not contract with the Center. If my insurance is Medicare, I certify that the information given by me in applying for payment under Title XVIII of the Social Security Administration Act is correct. 8. Investors: Your physician may be an investor in The Surgery Center at Lutheran. The receptionist, upon request, can provide more details regarding the ownership of the Center. Conditions of Service/Consent for Treatment 1 Patient Label The Surgery Center at Lutheran 9. Permission to Discuss Financial Information: I authorize (name of another adult other than myself) _____________________________, to discuss my account information with the Surgery Center at Lutheran. I understand that conversations will be limited to account balance, claim/personal payment, insurance benefits and insurance coverage. Medical information will not be discussed without further documented authorization. 10. Ride Arrangements: I have made arrangements to have a responsible adult drive me home and care for me for the next 24 hours. 11. During your stay with us: While you are at the Center we are committed to running on time. If you have been waiting for more than 15 minutes after your initial check-in, please alert the receptionist, who will check into the delay. The Center shall not be liable for the loss or damage to any money, jewelry, documents, dentures, glasses, hearing aides, clothing, etc. or other personal articles. Regarding the use of Cell Phones, they are prohibited in the surgical areas. The Surgery Center requests that usage be limited to the waiting area. 12. Permission: During your time at the Center and during your convalescence, the doctors and nurses are concerned about your care and may need to talk with your significant others to provide for the very best surgical outcome. Whom can we talk to: _________________________________ _______ Yes, my doctor or nurse can talk to my family/friends _______ Yes, my doctor or nurses may leave messages on my home phone, if I can not be reached 13. Payment: This Center expects each patient to pay his or her deductible and co-pays on or before the day of surgery. Once the insurance company has adjudicated the claim, patients will be responsible for all remaining balances. The Surgery Center at Lutheran will allow patients up to three months to pay off the remaining balance. It is the responsibility of the patient to contact the Business Office Manager, to request a 3-month payment plan. 14. Authorization: The undersigned certifies that he/she has read the foregoing, received a copy thereof, and as the patient, or the patient’s legal representative, or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms. The signature constitutes your acknowledgement that (1) you have read and agree to the foregoing; (2) that the operation, procedure and/or treatment has been adequately explained to you by the physician; (3) that you authorize and consent to the performance of the operation, procedure and/or treatment at this facility; (4) that you have read the Patient’s Rights and Responsibilities. When signing this form you are consenting to the performance of all routine medical/surgical care and treatment (e.g., physical examination, tests, x-rays, therapy, etc.) which may be performed while a patient at The Surgery Center at Lutheran, as well as emergency treatment or services that may be required under the general and special instructions of the patient’s physician or surgeon. ________ ______________ _______________ Signature (patient/parent/guardian) _______________________________________________ Witness Signature (if signed by other than patient) Date Time ________________________________ Relationship to patient I have received information in language I understand and have been given an opportunity to ask questions about: Please initial the items that apply. ___Advance Directives ____I have provided a copy of my Advance Directives to the Surgery Center ___My Rights and Responsibilities as a patient ___My physician’s part ownership in the Surgery Center Conditions of Service/Consent for Treatment 2 ___HIPAA/Notice of privacy practices Patient Label The Surgery Center at Lutheran Conditions of Service / Consent for Treatment 1. El Centro de Cirugía mantiene personal e instalaciones para ayudar a su médico (s) en su desempeño de varias operaciones quirúrgicas y otros procedimientos diagnósticos o terapéuticos especiales y / o tratamiento. Estos procedimientos pueden involucrar todos los riesgos de resultados fallidos, complicaciones, lesiones e incluso la muerte, por tanto conocidos como causas imprevistas, y ninguna garantía en cuanto al resultado o la cura. Usted tiene el derecho de ser informado de dichos riesgos, así como la naturaleza de la operación, el procedimiento y / o tratamiento, los beneficios o los efectos de la misma, y los métodos alternativos disponibles y sus riesgos y beneficios. Excepto en casos de emergencia, operaciones, procedimientos y / o tratamientos no se realizan hasta que haya tenido la oportunidad de recibir esta información y ha dado su consentimiento. Usted tiene el derecho de aceptar o rechazar cualquier propuesta de operación, el procedimiento y / o tratamiento en cualquier momento anterior a su rendimiento. 2. La operación, procedimiento y / o tratamiento se llevará a cabo por mi médico (o en el caso de una emergencia que causa su incapacidad para completar el procedimiento, un médico sustituto calificado o cirujano), junto con asociados y asistentes, incluyendo anestesiólogos, patólogos y radiólogos del personal médico para que el médico o cirujano pueden asignar responsabilidades designado. La persona en la asistencia con el propósito de llevar a cabo los servicios médicos especializados, tales como anestesia, radiología o patología no son agentes, funcionarios o empleados del Centro o su médico o cirujano, pero son contratistas independientes y, por lo tanto, sus agentes, empleados, o empleados. 3. El patólogo queda autorizado para usar su discreción en la eliminación de cualquier miembro, órgano o de otro tejido removido de su persona durante las operaciones o procedimientos establecidos anteriormente. 4. Directivas Anticipadas: Entiendo que a pesar de que los médicos y el personal del Centro de Cirugía respetan mis derechos a participar en las decisiones sobre mi cuidado de salud, la política del Centro de Cirugía es que todos los pacientes sometidos a procedimientos quirúrgicos se considerarán elegibles para tratamientos DE emergencia para mantener la vida. 5. En el evento de una emergencia o situación urgente: Doy mi consentimiento para ser transferido y/o ser admitido a una institución cercana para la continuación de tratamiento. En caso de una transferencia de emergencia a otra institución u hospital, doy mi consentimiento para el uso de sangre o subproducto de sangre en la facultad que me reciba.(Ponga sus iniciales en la línea apropiada) _______Si, estoy de acuerdo en recibir una transfusión de sangre en caso de emergencia. _______ No, no quiero recibir una transfusión de sangre aunque sea emergencia. En caso de una emergencia: Notifique mi pariente más cercano: Nombre: ______________________________ Teléfono: _________________ 6. Exposición accidental: En el evento de que haya una exposición accidental de mi sangre o fluidos a un doctor, contratista o empleado de la institución, doy mi consentimiento a una prueba del VIH y Hepatitis. 7. Obligación del Plan de Salud: Este Centro mantiene una lista de los planes de salud con el que contrata. Una lista de este tipo de planes está disponible a su petición en la Oficina Administrativa de este Centro. El Centro no tiene contrato, expresa o implícita, con ningún plan de salud que no aparece en la lista. El suscrito acepta que él / ella tiene la obligación individual de pagar los cargos completos de todos los servicios prestados a él / ella si él / ella pertenece a un plan que no tiene contrato con el Centro. Si mi seguro es Medicare, certifico que la información dada por mí en la solicitud de pago bajo el Título XVIII de la Ley de la Administración de Seguro Social es correcta. 8. Inversores: Su médico puede ser un inversor en el Centro Luterano de Cirugía. La recepcionista, a su petición, puede proporcionar más detalles con respecto a la titularidad del centro. 9. Permiso para discutir información financiera: Yo autorizo a (nombre de otro adulto que no sea yo) _____________________________, para discutir mi información sobre mi cuenta con el Centro Luterano de Cirugías. Yo entiendo que las conversaciones serán limitadas al balance de mi cuenta, reclamo/pago personal, beneficios y coberturas del seguro medico. Información sobre mi salud no será discutida sin autorización por escrito. Conditions of Service/Consent for Treatment 1 Patient Label The Surgery Center at Lutheran 10. Arreglo de viaje: He hecho planes para que un adulto responsable venga por mí, me lleve a casa y cuide por mí las siguientes 24 horas. 11. Durante su estancia con nosotros: Mientras que usted está en el Centro, estamos comprometidos a siempre estar a tiempo. Si usted ha estado esperando por más de 15 minutos después de su llegada, por favor avise a la recepcionista, que comprobará la demora. El Centro no se hace responsable por la pérdida o daño de cualquier dinero, joyas, documentos, dentaduras, gafas, audífonos, ropa, etc. u otros artículos personales. En cuanto al uso de los teléfonos celulares, están prohibidos en las áreas quirúrgicas. El Centro de Cirugía solicita que el uso se limita a la zona de espera. 12. Permiso: Durante su tiempo en el Centro y durante su convalecencia, los médicos y enfermeras se preocupan por su cuidado y puede que tengan que hablar con sus familiares para proporcionar el mejor resultado quirúrgico. Con quienes podemos hablar: _________________________________ _______ Sí, mi doctor o enfermera pueden hablar con mis familiares/amistades. _______ Sí, mi doctor o enfermera pueden dejar recados en mi teléfono de casa en caso de no estar disponible. 13. Pago: Este Centro espera que cada paciente pague su deducible y co-pagos en o antes del día de la cirugía. Una vez que la compañía de seguros ha adjudicado el reclamo, los pacientes serán responsables de todos los saldos restantes. El Centro Luterano de Cirugía permitirá a los pacientes tres meses para pagar el saldo restante. Es la responsabilidad del paciente mantenerse en contacto con el Gerente de la Oficina de Empresas, para solicitar un plan de pago de 3 meses. 14. Autorización: El firmante abajo certifica que él / ella ha leído lo anterior, recibió una copia del mismo, y que el paciente o el representante legal del paciente, o está debidamente autorizado por el paciente como agente general del paciente para ejecutar lo anterior y aceptar sus términos. La firma constituye el reconocimiento de que (1) usted ha leído y está de acuerdo con lo anterior, (2) que la operación, procedimiento y / o tratamiento se ha explicado adecuadamente a usted por el médico, (3) que autoriza y consiente el rendimiento de la operación, el procedimiento y / o tratamiento en nuestro centro, (4) que ha leído los Derechos y Responsabilidades del Paciente. Al firmar este formulario, usted da su consentimiento para la realización de todos los cuidados de rutina médica / quirúrgica y el tratamiento (por ejemplo, la exploración física, las pruebas, radiografías, terapia, etc.) que puede realizarse mientras el paciente está en el Centro Luterano de Cirugía, así como el tratamiento de emergencia o servicios que pueden ser necesarios en virtud de las instrucciones generales y especiales del médico o cirujano del paciente. ________ Firma (paciente, padre, tutor) _______________________________________________ Firma de testigo (si fue firmado por alguien mas) ______________ _______________ Fecha Hora ________________________________ Relación al paciente He recibido la información en un idioma que yo entiendo y me han dado la oportunidad de hacer preguntas. Por favor ponga sus iniciales en lo que aplique a usted. ___Directivas Avanzadas ____He recibido una copia de mis directivas avanzadas del centro quirúrgico. ___Mis derechos y responsabilidades como paciente. ___ Parte responsabilidad de mi médico en el Centro de Cirugía ___HIPAA/Notificación de prácticas privadas Conditions of Service/Consent for Treatment 2 Patient Label Frequently Asked Questions General Questions Where can I find directions to The Surgery Center at Lutheran? Follow this link to our Maps and Directions page where you will find driving directions and parking information. What are the hours of operation for the Surgery Center? Our clinical hours of operation are 6:15 am to 5 pm. Business hours are 8 am to 5 pm. Does the Surgery Center have a parking lot? Yes, we provide free parking to our visitors. The parking lot is located directly south of the building. Do you have a cafeteria at the Surgery Center? We do not have a cafeteria at our facility. We provide coffee and there is a soda machine and a vending machine with snacks in the waiting area for families. There are many restaurants in the area as well as a cafeteria at the hospital on campus. What does NPO mean? NPO stands for "nothing by mouth." This includes water, gum (gum increases natural saliva production), hard candy, chewing tobacco, food and drink. What should I wear the day of my procedure? You will be provided a surgical gown to wear during your procedure. Please wear loose, simple, comfortable clothing and comfortable walking shoes. Leave all jewelry at home. Please keep in mind what procedure is being performed and bring clothes that are appropriate for your return home. For example, for shoulder surgeries, loose button-up shirts are best. For leg surgeries, loose shorts or pants are recommended. Whichever site you are having worked on, wear something that will accommodate a bandage, cast or other type of dressing. If you are having a pain injection, wear elastic loose fitting pants and avoid wearing jeans or pants with metal around the waist area, such as zippers, grommets or buttons. Please remember to leave all valuables at home. Why do I have to arrive so early before my surgery? There are many things we need to do to prepare for your surgery. A registered nurse or nurses will take your vital signs, wash and remove hair from your surgical area, review your medical history and medications, and start your IV. We will take time to discuss your surgery with you, answer any questions you may have and review instructions for your return home. You will also visit with your surgeon and anesthesiologist prior to your surgery. If your surgeon has requested your anesthesiologist to provide you with a pain management block as part of your anesthetic, this will be performed before your surgery. Will I have my surgery at the time I am scheduled? Your scheduled surgery time is an estimated time. Surgeries may take a shorter or longer amount of time than planned; therefore, we cannot provide you with an exact scheduled time. We will make every effort to meet your expected surgery time and will keep you and your family informed of any delays. Pre-Procedure Why can't I have anything to eat or drink several hours before surgery? There are several reasons for this rule. First, if there are contents remaining in your stomach at the time of surgery, you are more likely to get nauseated and possibly vomit after surgery. Second, during sedation or anesthesia, when anything is present in your stomach, including water, excess saliva, food or drink, these contents can be regurgitated and inhaled into your lungs. This may cause complications, including severe pneumonia. Why should I fill prescriptions my physician has given me before I have my surgery? After your procedure, you may be tired and groggy and may not be up to a trip to the pharmacy. Filling your prescriptions beforehand will be easier on you and you will have pain medications on hand when you need them. Please bring them with you when you have surgery. Do I need crutches? If you are having any surgery on your lower extremities, ask your physician if you will need crutches. If possible, please bring the crutches with you. What should I bring? Bring a case for your glasses, contacts and dentures. Bring reading glasses if needed. Bring your folder if you were given one at the doctor’s office. Bring crutches, ice machine, brace, boot or sling if needed. Bring your inhaler, CPAP, and insulin if discussed. Bring a photo ID, your insurance card and a form of payment if you have been notified of a copay, deductible and/or co-insurance amount due on the day of your procedure. All jewelry and piercings need to be removed. It is best to leave all valuables at home or with your family. Will my family be able to stay with me while I am being prepared for my surgery? Yes, you may have a friend or family member with you during the preparation for surgery. We prefer you limit visitors to one friend or family member as the rooms are small. If possible, make arrangements for someone to care for your children the day of the surgery. We do our best to provide a calm, quiet area for our patients while they recover at our surgery center. Post-Procedure Will I be able to see my family after my surgery? There is a period of time that you will be in the recovery room. One friend or family member may join you in the post-operative recovery room depending on your nursing needs. How will I feel after my procedure? You may feel groggy and tired. You may feel cold or have some chills. Warm blankets are available. Noises may seem louder than usual. Your vision may be blurred and you may have a dry mouth. You may feel some discomfort. If needed, your recovery room nurse can give you pain and nausea medications that your anesthesiologist and surgeon have ordered for you. What can I do to minimize pain after surgery? If you are having a surgical procedure, it is normal to experience pain afterwards. If you have been given a prescription for pain medications, get them filled as soon as possible, preferably before surgery and bring them with you to the surgery center. Stay on top of your pain by taking the pain medication when you first become aware of pain sensations. Remember to always eat before taking pain medications to avoid nausea. Detailed discharge instructions will be provided based on your specific surgery. When will I be allowed to go home? Everyone reacts differently to surgery and anesthesia, so recovery time depends upon the individual. When you are awake, doing well and feel ready to go home, your nurse will review your post-operative instructions with your responsible party, then allow you to go home. If you receive anesthesia or sedation, you will need to have a responsible adult with you for the first 24 hours to help you with your care. Your safety is our primary concern. Do I need someone to drive me home and stay with me after my procedure? Yes, you will need to have a responsible adult take you home after any procedure requiring sedation or anesthesia. This is for your safety. You will need someone available to assist you at home. Patients cannot drive for 24 hours after having sedation or anesthesia. When can I resume my usual activities? Go back to work? Drive a car? With regard to driving a car, going back to work or resuming exercises, etc., ask your surgeon, who will explain any limitation(s) you may have. What signs should I watch for when I go home? Notify your physician immediately if you experience any excessive bleeding, signs of infection (redness, swelling, heat, increased pain, red streaks, drainage from the wound, fever of 100.6 degrees or higher), difficulty breathing, excessive pain, excessive nausea and vomiting, inability to urinate, shortness of breath or if you have any new pain in either calf area. For any other concerns or problems, contact your physician or, during business hours, the Surgery Center at 303-301-7700. In case of an emergency call 911. Contacting The Surgery Center at Lutheran Who do I contact for questions regarding payment or insurance coverage for an upcoming procedure? Please contact the Surgery Center Business Office at 303-301-7700. Who do I contact for questions regarding my bill? Please contact Specialty Billing Solutions at 720-359-2110. Please identify the Surgery Center at Lutheran as your surgical facility to ensure that you are connected to the correct representative. Who do I contact for questions regarding preoperative clinical questions? Please call 303-301-7708 and ask to speak to a pre-operative assessment nurse. If your call goes to voice mail, please leave a message; we check our voice mail box frequently throughout the day. Who do I contact for questions regarding lab or pathology results? Please contact your physician's office. Who do I contact for questions regarding medical records? Please contact the Business Office at 303-301-7700. A release authorization will be required. Who do I contact if I have a grievance? Please call the Center at 303-301-7700 and ask to speak to a Management Representative to file a formal grievance. Information About Billing Procedures Using information obtained from your surgeon’s office, our business office staff will call your insurance company prior to surgery to verify your medical benefits for our facility charge. We will secure any information regarding co-payments, coinsurance, and/or deductible amounts that will be your responsibility. Payment of your share of charges is expected in full prior to or on the day of your procedure. Your insurance company will receive a bill for the services provided by The Surgery Center at Lutheran. This covers your preoperative evaluation, most supplies and medications, equipment, personnel, and use of the operating and recovery rooms. If you have no insurance or if your insurance does not cover the procedure to be performed, please make arrangements to pay the Surgery Center facility fee before or on the day of the surgery. For your convenience, we accept cash, personal checks and Visa/MasterCard. In addition to the facility fee charges, you will/may receive separate bills for the following services: Your Physician or Surgeon, Anesthesia (if you received general anesthesia or it was necessary for a nurse anesthetist or an anesthesiologist to be available for your procedure), Laboratory tests, if they were required by your physician, and/ or Pathology, if tissues or specimens were removed during surgery. Any questions regarding these services should be directed to the billing offices of the appropriate provider. Our business office staff will be happy to answer any questions you may have regarding insurance coverage or billing procedures if you call 303.301.7700. Thank you for choosing The Surgery Center at Lutheran for your healthcare services. We appreciate the opportunity to serve you. Information About Your Bill Our billing services are provided by PINNACLE III’S Specialty Billing Solutions, a centralized billing office located in Denver, Colorado. They are responsible for filing claims with your insurance carrier as well as collecting any balances attributed to your responsibility by your insurance carrier. PINNACLE III’S Specialty Billing Solutions employees may contact you regarding your insurance coverage related to The Surgery Center at Lutheran in an effort to get your account paid appropriately. If your insurance provides 100% coverage and there are no other balances due, you may not receive a statement or bill. The bill for any balances due will be sent to you by PINNACLE III’S Specialty Billing Solutions. Payment of any balance due is expected within 3 months. If you are unable to pay your balance in full, please contact Specialty Billing Solutions to establish payment arrangements. If you have questions regarding a bill or statement received, please contact Specialty Billing Solutions at the number listed below. They will have the information necessary to answer your questions and will be happy to assist you. For billing questions: Please send payments to: Specialty Billing Solutions PINNACLE III (720) 359-2101 (877) 852-7552 toll free Lutheran Campus ASC, LLC. P.O. Box 674245 Dallas, TX 75267-4245 Surgery For Children The Surgery Center at Lutheran was designed to accommodate the special needs of our pediatric patients. The Center has a highly qualified nursing staff and the anesthesia team has extensive training and experience with children. We welcome you to tour the Center and ask any questions you may have prior to your child’s procedure. Bring a favorite toy or comfort item along to put your child at ease. WHERE to find The Surgery Center at Lutheran The Surgery Center at Lutheran is located in the Medical Pavilions Building. 3455 Lutheran Parkway, Suite 150, First Floor. The Center is easily reached off of 32nd Avenue on Lutheran Parkway located between Wadsworth and Kipling Streets. Enter off of 32 nd onto Lutheran Parkway which is marked by a large sign, Exempla Lutheran Medical Center. Entrance #7
