Nurse Making Notes

Transparency in Healthcare

A Happier, Healthier You

At the Center For Specialized Surgery, scheduling and being well informed has become simpler than ever before.

Our personalized team provide patients with the resources they need leaving our clinic well informed - both medically and financially.

You are always welcome to a copy of the Financial Estimate that we provide prior to your surgical procedure.

Additionally, the following information will be discussed with you prior to your procedure:

Authorization for Release of Information
I authorize the Center for Specialized Surgery to release medical information concerning the procedure(s) performed at this location as may be requested by third party payors in order to assure processing of my claim for the procedure.

Credit Policy
A Claim will be filed with your insurance carrier as expeditiously as possible. You will be notified upon final claim resolution should there be any additional monies due from you. If funds are due, it is expected that payment will be received no later than ten (1) days from receipt of a statement/notice advising you of the balance. In the event that such amount if placed with a collection agency/attorney, you will be responsible for any and all collection fees, attorney fees and court costs.

Assignment of Insurance Benefits
I hereby authorize payment directly to the Center for Specialized Surgery for any insurance benefits otherwise payment to me or on my behalf for the procedures(s) performed at the Center for Specialized Surgery. It is agreed that payment to the Center for Specialized Surgery, pursuant to this Assignment of Benefits, by an insurance company shall discharge the insurance company of any and all obligations under a policy to the extent of such payment. I understand that I am financially responsible for any charges not covered by this Assignment of Benefits. This Assignment of Benefits is valid for all insurance companies and programs, including Medicare.

Charges
Charges for service provided by the Center for Specialized Surgery consist of two components:
1. A Base charge ; and,
2. Possible Separate & itemized charges

The estimated base fee for your procedure is $ ___________________________. The amount for the itemized charges cannot be estimated in advance of your procedure; it is however anticipated that those charges may be equal to or greater than the base fee.

Please note that the physician/surgeon services/fee and the Anesthesiologist/CRNA fee are separate and not included in the Center for Specialized Surgery’s fee, and the responsibility for payment to your physician/surgeon and Anesthesiologist/CRNA is not handled by the Center for Specialized Surgery. Please contact your surgeon directly and/or Spine Diagnostics & Interventional Center at (813) 872-9200 for additional information on your anesthesia fees and the insurance plans they accept.

For additional information provided by the State of Florida, Agency for Healthcare Administration regarding ASCs and other facilities/physicians, please go to www.FloridaHealthFinder.gov