SAFETY HARBOR SURGERY CENTER This facility is required by the State of Florida to ask you to complete the information below and we are required to provide you with documents specified: RECEIPT OF PATIENT RIGHTS AND RESPONSIBILITIES AND NOTICE OF PRIVACY PRACTICES: I give permission for my protected health information to be disclosed for purposes of communication results, findings and care decisions to family members and others listed below: Name: ______________________________________

Name:__________________________________

Name: ______________________________________

Name:__________________________________

In accordance with Medicare’s Conditions of Coverage for Ambulatory Surgical Centers, the following information has been provided to you, verbally and in writing, at least 24 hours prior to your date of procedure at Safety Harbor Surgery Center. ADVANCE DIRECTIVES and CONSENT TO TRANSFER in the event of an emergency: Please check “I do” or “do not” for both items below. Please do not leave blank I DO ____, DO NOT ____ have an Advance Directive, Living Will or Health Care Power of Attorney. I DO ____, DO NOT ____ want to have information on Advance Directives. I may visit the State of Florida web site for Florida Advance Directive information. It is our Policy, regardless of the contents of any Advance Directive or instructions from a Health Care Surrogate or Attorney in fact, that if an adverse event occurs during your treatment at this facility, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. Your Advance Directive or Health Care Power of Attorney will become effective again after your transfer from this facility. My signature below acknowledges that I am in agreement with this policy and does not revoke or invalidate any current health care directive or health care power of attorney. I may receive a copy of Advance Directive information upon admission to the center, if desired. Also by my signature on this document, I acknowledge receipt of my Patient Rights and Responsibilities, a Notice of Privacy Practices brochure, and information on the facility grievance process. Your physician may be an owner in the Safety Harbor Surgery Center, LLC. Owners include: Dr. Umesh Choudhry; Dr. Dana Deupree; Dr. Theodore Small; Dr. Robert Davidson; Dr. Satinderpal Sondhi; Dr. Brian Oliver. _____________________________________________ Patient Signature

_____________________________ Date

_____________________________________________ Guardian Signature

_____________________________ Date

Safety Harbor Surgery Center Patient Consent to the Use and Disclosure of Health Information For Treatment, Payment, or Healthcare Operations, per HIPAA Regulations I understand that as part of my health care, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination, and test results, diagnoses, treatments, and any plans for future care or treatment. I understand that this information serves as: • A basis for planning my care and treatment • A means of communication among the health professionals who contribute to my care, such as referrals • A source of information for applying my diagnosis and treatment information to my bill • A means by which a third-party payer can verify that services billed were actually rendered • A tool for routine health care operations, such as assessing quality and reviewing the competence of staff I have been given the “Notice of Patient Privacy Practices” that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: • The right to review the “Notice” prior to acknowledging this consent • The right to restrict or revoke the use or disclosure of my health information for other uses or purposes • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations. PLEASE PRINT Restrictions: I request the following restrictions to the use or disclosure of my health information: ______________________________________________________________________________________ Please indicate below (by name and relationship), the persons with whom we may discuss your protected health information: ______________________________________________________________________________________ ______________________________________________________________________________________ Messages or appointment reminders: May leave a message at your home using your doctor’s/practice name: Yes May leave a message at your work using your doctor’s/practice name: Yes Messages will be of non-sensitive nature, such as, appointment reminders.

No No

I understand that as part of treatment, payment, or health care operations, it may become necessary to disclose health information to another entity, i.e., referrals to other health care providers. I consent to such disclosure for these uses as permitted by law. I fully understand and accept/decline (please circle one) the information in this consent. _________________________________ Patient/Guardian Signature

________________________ Date

_________________________________ Printed Name of Signer If other than the patient, _________________________________ signing, because I am the legal guardian, custodian or have Power of Attorney for this patient, for treatment, payment, or health care operations. ************************************************************************************** FOR OFFICE USE ONLY Consent form received and reviewed by ______________________________________ on __________________ Consent form signature refused by patient Patient unable to sign consent form, reason: __________________________________________

PATIENT INFORMATION PASS-CODE. The privacy of patient information is second only in importance to patient care itself. In order to better protect your privacy, we are assigning a four-digit pass-code for you to give to the family members and friends whom you would like us to share your personal health information. The family member or friend seeking information will need to provide this pass-code to the nurse or other hospital employee that they are speaking with, in order to receive any information other than general condition. This pass-code will serve as your authorization to disclose your personal health information for purposes such as communicating results, findings, and care decisions to family members and friends. The facility is not responsible for the distribution of this pass-code and will assume that the patient is taking reasonable measures to protect the pass-code given.

YOUR PATIENT PASS-CODE IS:

Date of Birth or Last Four Digits of Social Security Number

USES AND DISCLOSURES FOR CARE PURPOSES PATIENT PASS-CODE CHANGE FORM This form should be used only to change the currently active patient pass-code used to disclose PHI to a patient’s immediate family member, other relative, or a close personal friend of the patient, or any other person to whom the patient has given his or her password. It is the patient’s responsibility to update family and friends of change. This policy does not apply to information available in the facility directory. Note: Releases that have already been made with the prior code are not applicable under this form. Allow appropriate time for all personnel to be informed.

Patient Name: ______________________________________________________________________ Account number: ___________________________________ Date Requested: __________________________ Previous 4-digit Pass-code: ___ ___ ___ ___ New 4-digit Pass-code: ___ ___ ___ ___

I understand that my personal health information will be given to all persons that call and provide the above pass-code.

Patient Signature:

Date:

Safety Harbor Surgery Center New Patient Registration

Dear Patient: Safety Harbor Surgery Center is interested in knowing how you heard about us. Please take a moment to check off the source of your referral.

Physician (name) ___________________________________________ Friend (name) ______________________________________________ Newspaper (which one) ______________________________________ Brochure Billboard Mailing Radio Television Yellow/White Pages Other (explain) ________________________________________________

Thank You for Your Time!

___________________________________ Patient Printed Name Medical Record # ____________________

___________________ Date

Safety Harbor Surgery Center, LLC Patient Agreement and Consent 1. CHOICE IN HEALTHCARE FACILITIES: You have healthcare choices. These are a few alternative facilities available to you: Mease Countryside Hospital 3231 McMullen Booth Road Safety Harbor, Florida 34695 (727) 725-6111

Mease Dunedin Hospital 601 Main Street Dunedin, Florida 34698 (727) 733-1111

Morton Plant Hospital 300 Pinellas Street Clearwater, Florida 33756 (727) 462-7000

2. CONSENT TO TREATMENT: I hereby authorize the physician in charge of my care the Surgery Center to provide services including, but not limited to, emergency medical services, routine, diagnostic procedures, and medical procedures as their judgment may deem necessary or advisable. I acknowledge that any physicians and surgeons furnishing services to me including, but not limited to, radiologists, anesthesiologists, and pathologists are independent contractors with me and are not employees, agents or servants of the Surgery Center. I further understand that I am under the care and supervision of my surgeon and that it is my surgeon’s sole responsibility to obtain my informed consent when required for medical, surgical, diagnostic, or therapeutic procedures, or facility services rendered to me under the general or special instructions of my surgeon. 3. AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I hereby authorize the Surgery Center and/or any treating physicians, and my insurance company to obtain, or my attorney, use and/or release information (current and historical) for the purposes of treatment, payment, and/or operations, as outlined in the Notice of Privacy Practices. This may include collection agencies, credit bureaus, and myself, and will be limited to the minimum amount necessary. 4. MEDICARE/ MEDIGAP/ MEDICAID PATIENT CERTIFICATION/ RELEASE OF INFORMATION AND PAYMENT REQUEST: I certify that the information given to apply for payment under Title XVIII and/or Title XIX, of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare, Medigap or Medicaid for payment. I understand that I am responsible for any health insurance deductibles and co-payments. 5. ASSIGNMENT OF INSURANCE BENEFITS AND GUARANTEE OF PAYMENT: I hereby authorize, request and direct any and all assigned insurance companies to pay directly to the Surgery Center and/or my treating physician the amount due me in my pending claims for facility benefits under the respective policies. For value received, including but not limited to the services rendered, I agree to guarantee and promise to pay the Surgery Center and any treating physicians, all charges and expenses incurred in my treatment, including those expenses not covered by any insurance policy presently in force, including any co-payment and/or deductible. Unless specifically agreed in writing, all charges shall be

paid at discharge. Unpaid accounts shall bear interest at the rate provided by law, whether suit is brought or appeal taken. If any action at law or in equity is brought to enforce this agreement, the facility and/or treating physicians shall be entitled to recover attorney’s fees, court costs, and any other costs of collection incurred. 6. RELEASE OF RESPONSIBILITY AND LIABILITY FOR PERSONAL VALUABLES: I understand that the Surgery Center discourages retaining personal valuables while at the center and agree that the Surgery Center is not responsible for valuables or belongings brought into the facility. Personal valuables or belongings include, but are not limited to, clothing, dentures, glasses, prosthetic devices (such as hearing aids, artificial limbs, or assist devices such as: canes, walkers, or wheelchairs), credit cards, jewelry and money. 7. I understand that my physician may be an owner in the Safety Harbor Surgery Center. I know I have the right to ask for further information. 8. PLEASE INDICATE THE CORRECT ANSWERS BELOW: 1 2 3 4

Are you currently receiving Medicare Benefits? (If yes, answer 2, 3, & 4) ____Yes ____No Are either you or your spouse currently working? ____Yes ____No Are either you or your spouse currently provided with any group health coverage? ____Yes ____No Are you currently receiving any other health care benefits (i.e. Black Lung, Veterans Affairs, government program research grant, work, non-work, or automobile accident related injury or illness benefits)? ____Yes ____No

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS DOCUMENT HAS BEEN READ BY OR EXPLAINED TO ME AND I UNDERSTAND THIS INFORMATION. I WILL RECEIVE A COPY OF THIS DOCUMENT UPON REQUEST. I ACKNOWLEDGE THAT A COPY OF THIS DOCUMENT SHALL BE AS EFFECTIVE AS THE ORIGINAL.

Patient Signature: _________________________________________ Date: _______________________ Signature of Patient’s Authorized Representative: _____________________________________________ Relationship to Patient: __________________________________________________________________ Surgery Center Representative: ____________________________________________________________

Guest Registration Information & Check in Sheet Have you even been a patient at the Safety Harbor Surgery Center in the past?

YES

NO

Patient Name: __________________________________ __________________________________ Last First Date of Birth: ______________________ Soc. Security Number: _____________________ Male

_____ M.I. Female

Complete Address: _____________________________________________________________________________ _______________________________________________ City, State, ZIP Cellular Phone # ( Race: (circle one)

) ______________________ Black

White

Asian

Home Phone # (

Work Phone # ( Hispanic

(For our female guests) Is there a chance that you may be pregnant? YES NO Last menstruation Period _____________________

) _________________________

) ________________________________

Other _________________________________

Estimated Due Date ________________________

******* GUARANTOR INFO (ONLY complete if the patient is a minor (under 18 yrs) or incapacitated adult)******* Name of Guarantor ___________________________________ Soc Security # ____________________________ Guarantor’s Date of Birth __________________

Relationship to patient ______________________________

Address (only if different than patient) _____________________________________________________________ __________________________________________ Home Phone # ( City, State, Zip

) _____________________________

******* INSURANCE SUBSCRIBER INFO (complete ONLY if sub on the insurance policy is not the patient)******* Name of Subscriber ______________________________ Relationship to Guarantor ____ Spouse ____ Parent

Soc. Security # _____________________________

____ Other

Date of Birth ______________________

******* ACCIDENT INFO (please complete if service we are providing to you today is the result of an accident)****** Worker’s Comp _____

Auto Accident _____

Other ______

Date of Accident or Injury (day, month, year) _________________ Claim # _____________________________ Name of Insurance carrier, claims address, phone number and name of adjuster handling the claim:

_____________________________________________________________________________________ _____________________________________________________________________________________ *****Information below to be completed by Surgery Center Staff***** ______ ABN – Medicare Letter must be signed by patient, dates & witnessed by staff member ______ SCRIPT

______ Omega Response needed (Medicare Medical Necessity)

______ Copy of Ins Card

______ Ins info not verified

______ Ins info not entered into Signature

______ NFR - Notice of Financial Responsibility must be signed and dated by the patient & witnessed by staff ______ Collect Payment of $ __________ from patient ______ Self Pay/Estimated charges/Discount form must be signed and dated by the patient & witnessed by staff.

______ OTHER _____________________________________________________________________