Healthcare Surgery Center Services Agreement

HEALTHCARE SURGERY CENTER SERVICES AGREEMENT

Parties and Effective Date

Surgery Center Name:

Patient Name:

Date of Agreement:

Patient Information

Insurance and Billing

I authorize the Surgery Center to bill my insurance and to release medical information necessary to process claims. I understand I am financially responsible for any charges not covered by insurance and for co-payments, deductibles, and non-covered services.

Assignment of Benefits: I authorize payment of benefits to the Surgery Center for services rendered.

Procedure and Clinical Information

Medical History

Consent, Risks, and Alternatives

I acknowledge that the nature, purpose, benefits, and material risks of the procedure have been explained to me by my provider. Risks include, but are not limited to, infection, bleeding, adverse reaction to anesthesia or medication, scarring, persistent pain, and the possibility that the intended outcome may not be achieved. I understand alternative treatments and the risks of refusing treatment have been explained.

I consent to the performance of the described procedure, including any ancillary or additional procedures that the surgeon determines are necessary for safety or best clinical outcome.

Specific Consents (select all that apply):

Consent to administration of anesthetic agents (local, regional, sedation, general) as indicated.

Consent to blood transfusion if required emergently.

Consent to clinical photography for medical records and care.

Privacy, Records, and Authorization

I acknowledge receipt of the facility's privacy practices and consent to the release of my protected health information to the treating providers, insurers, and as required for continuation of care and payment. I authorize the Surgery Center to obtain and disclose medical information as necessary to facilitate treatment, payment, and healthcare operations.

Financial Terms and Collections

The patient or responsible party agrees to pay all charges for services rendered. If payment is not received, the Surgery Center may pursue collection, and the patient will be liable for collection costs, interest, and reasonable attorney fees. Estimates of charges are good-faith estimates and not guarantees of final costs.

Scheduling and Cancellation

Cancellation Policy: The patient agrees to provide at least days' notice for cancellation. Failure to provide timely notice may result in a cancellation fee and forfeiture of deposits.

Representations, Warranties, and Indemnity

Patient represents that all information provided is true and complete to the best of their knowledge. Patient agrees to indemnify and hold the Surgery Center and its staff harmless from claims arising from failure to provide accurate medical history or follow pre- and post-operative instructions.

Dispute Resolution

Parties agree that claims arising from this Agreement will first attempt good-faith negotiation. If unresolved, disputes may be submitted to mediation or binding arbitration as the exclusive remedy, subject to applicable law. Nothing herein prevents the Surgery Center from seeking injunctive relief when necessary to protect patient safety or facility operations.

Acknowledgment and Certification

I certify that I have read and understand this Agreement, that my questions have been answered, and that I consent to the performance of the procedure and related services described above. I understand I may withdraw consent prior to the procedure, subject to the facility's cancellation and scheduling policies.

HIPAA / Privacy Acknowledgment

By signing below, I acknowledge receipt of the Surgery Center's Notice of Privacy Practices and consent to the use and disclosure of my protected health information for purposes of treatment, payment, and healthcare operations as outlined above.

Authorization to Release Records: I authorize release of medical records to my insurer and other providers involved in my care.

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