As applicable, “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.”

Patients should contact each health care provider who will provide their service for an estimate of their charges.

“Patients and prospective patients may request from this facility and other health care providers a more personalized estimate of charges and other information. Patients and prospective patients should contact each health care practitioner who will provide services in the ASC to determine the health insurers and health maintenance organizations with which the health care practitioner participates as a network provider or preferred provider.”

“You should contact your insurer or health maintenance organization regarding your cost-sharing responsibilities.”

Lakeside Surgery Center
1825 North Mills Avenue
Orlando, FL 32803
407-206-2375

Advanced Directive

You have the right to submit an Advanced Directive

All patients have the right to make advance directives or to execute powers of attorney that authorize others to make decisions on the patient’s behalf based on their expressed wishes when unable to make or communicate decisions. This Center respects and uphold those rights.

Documentation in a prominent part of the patient’s current medical record indicates whether or not the individual has executed an advance directive.

However, unlike an acute care hospital setting, most procedures performed in this facility are minimal risk. Of course, no surgery is without risk, and you will discuss procedure specifics (risks, recovery, after-care) with your physician. Therefore, it is our policy, regardless of the contents of any advance directive or instructions from a healthcare surrogate, attorney-in-fact, or holder of a healthcare provider, that if an adverse event occurs during your treatment at the Center, we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. At the acute care hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, advance directive, or healthcare power of attorney.

For further clarification, please request to speak with the Center’s ASC Manager at the main ASC number, (407) 206-2375.

Caring Connections

You have the right to access the Advance Health Care Directive described in Caring Connections, a national program of the National Hospice and Palliative Care Organization (NHPCO).

This program, aimed at improving care at the end of life, includes:

• Instructions for completing the Florida Advance Directive for Healthcare
• Learning options for end-of-life services and care
• How to make sure that your wishes are honored
• How to tell your family, friends, and healthcare providers about your decision
• How to participate in personal and community efforts to improve end-of-life care
• A copy of the Florida Durable Power of Attorney for Healthcare

This information is available on the Caring Connections
website: https://www.caringinfo.org/?s=florida

Upon request, you, your representative, or your surrogate, can obtain a copy of your Florida’s Advance Directive form at the Center.

Good Faith Estimates

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
• Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
• Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.

Information on average pricing for procedures and to compare health procedure prices in Florida can be found on the Agency for Healthcare Administration website at https://price.healthfinder.fl.gov/

As a patient of the Center, I understand that any co-pays, co-insurance, and/or deductibles are due prior to having my procedure. I understand that the following provider fees are NOT INCLUDED in the surgery center fee and will be billed separately:

• Physician (surgeon) fee
• Anesthesiology fee
• Pathology, if applicable
• Laboratory services, if applicable

For any questions or concerns, please call (407) 206-2375.

Anesthesia

Nature Coast Anesthesia Providers, P.A.

17560 US Highway 441 Mount Dora Florida, 32757-6711 / 386.697.1364

Grievances

Voice Your Concerns or Suggestions

Without fear of reprisal, voice grievances regarding treatment or care, changes in policy and service, or other comments to:

The Center

Attn: Clinical Director
1825 N Mills Avenue Orlando FL 32803

Phone: 407-206-2375

Florida Agency for Health Care Administration Complaint Administration Unit:

If you wish to file a complaint against a licensed health care facility regulated by the Agency for Health Care Administration, please contact us at 1-888-419-3456 / 800-955-8771 Florida Relay Service (TDD number) or use our Licensed Health Care Facility Complaint Form: https://apps.ahca.myflorida.com/hcfc/

A complainant may provide their name, address, and phone number to the Department. All complaints are confidential.

Medicare

The Office of the Medicare Ombudsman

https://www.medicare.gov/basics/your-medicare-rights/get-help-with-your-rights-protections
or 1-800-MEDICARE.

For more information regarding quality measures and statistics disseminated by AHCA pursuant to s.408.05, F.S., visit www.floridahealthfinder.gov

Payment, Billing & Assistance Policies