Medicare Condition of Coverage

Dear Patient:

Enclosed you will find notice entitled Medicare Conditions for Coverage. As a Medicare certified ambulatory surgery center we are mandated to share this information with all patients, regardless of your insurance coverage, PRIOR TO THE DATE OF YOUR SURGERY. When you arrive at Algonquin Road Surgery Center, you will be asked to sign a form indicating you have received and reviewed the enclosed information. If you choose to not sign this form, your procedure will be cancelled.

If you have any questions, please contact the surgery center at 847.458.1246.

Thank you and we look forward to seeing you soon.

Please review all information thoroughly.

MEDICARE CONDITION OF COVERAGE

All rights will be given to each patient and exercised without regard to sex, culture, economic, educational, or religious background or the source of payment for his/her care. Each patient has the right to: Patient Bill of Rights

Respectful and considerate care.
Knowledge of the name of the physician who has primary responsibility for coordinating his/her care and the names and professional relationships of other physicians who will see them.
Receive information from his/her physician about his/her illness; his/her course of treatment and his/her prospects for recovery in terminology that is understandable to each patient on an individual basis.
Receive as much information about any proposed treatment or procedure as he/she may need in order to give informed consent or to refuse this course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved and knowledge of the name of the person who will carry out the procedure or treatment.
Participate actively in decisions regarding his/her medical care. To the extent permitted by law, including the right to refuse treatment.
Full consideration of privacy concerning his/her medical care program. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly. The patient has the right to know the reason for the presence of any individual.
Confidential treatment of all communications and records pertaining to his/her care and his/her stay in the organization. His/her written permission shall be obtained before his/her medical records can be made available to anyone not directly concerned with his/her care.
Reasonable responses to reasonable requests he/she may make for service.
Leave the organization against the advice of his/her physician.
Reasonable continuity of care, and to know in advance, the time, location of appointment, and the physician providing the care.
Be advised if the organization or physician proposes to engage in or perform human experimentation affecting his/her care or treatment. The patient has the right to refuse to participate in any such research projects.
Be informed by his/her physician or a delegate of his/her physician of his/her continuing health care requirements following his/her discharge from the organization.
Be free of harassment.

If you have any question or concern about your medical care, or safety issues, you may alert a staff member or call/ contact the Administrator at 847-458-1246. William Bell, Acting Deputy Director, The Health Facilities Division of the Illinois Department of Health Care Regulations, 525 W Jefferson St. 5th Floor, Springfield, IL 62761 1-800-252 -4343 or www.medicare.gov/Ombudsman. The Joint Commission on Accreditation of Health Care Organizations at 1-800-994-6610, or www.jointcommission.org/GeneralPublic/Complaint, You may also report Health Care concerns by writing to Community Senior Services Associates, Inc. 101 S. Grove Ave. Elgin, IL 60120.

Patients Responsibilities

The organization expects that a patient will provide accurate and complete information about matters relating to his/her health history in order for the patient to receive effective medical treatment.
A patient is responsible for reporting whether he/she clearly comprehends a contemplated course of action and what is expected of them.
The organization expects that a patient will cooperate with personnel and ask questions if directions and/or procedures are not clearly understood.
A patient is expected to be considerate of other patients and the organization’s personnel, and to observe the smoking policy of the organization. A patient is also expected to be respectful of the property of other persons and the property of the organization.
A patient is expected to help the physicians, nurses, and allied health personnel in their efforts to care for the patient by following their instructions and medical orders both in the organization, and if applicable, outside the organization (i.e. at their home).
It is understood that a patient assumes the financial responsibility of paying for all services rendered whether through third party payers (his/her insurance company) or being personally responsible for payment for any services that are not covered by his/her insurance policies.
It is expected that the patient will not take any drugs which have not been prescribed by his/her attending physician and/or prescribed or administered by the organization’s staff and shall fully disclose any drugs and/or other substances which the patient may have ingested and which could affect the current course of treatment contemplated at the organization.

Advanced Directives

Advanced Directives are discussed upon your pre admission evaluation as well as a copy sent to you upon your request.

PHYSICIAN FINANCIAL INTERESTS
The following physicians have a financial interest/ownership in Algonquin Road Surgery Center:

Elgin Gastroenterology Investments, LLC
Dr. John Daniels
Dr. Rolando Izquierdo
Dr. Kelly Holtkamp
Dr. Steve Rochell
Dr. Timothy Havenhill
Dr. Jagbir Ahuja
Dr. Christopher Standage
Dr. George Stankevych

Affilitated Ear, Nose and Throat Physicians
Dr. Roman Dykun
Dr. Sihun Kim
Dr. Andrew Ward
Dr. Raja Chatterji
Dr. Humberto Lamoutte
Dr. Deepak Khurana
Dr. Michael Kogan
Dr. Safwan Barakat

Dr. Rockne Brubaker
Dr. David Turok
Dr. Brett Becker
United Anesthesiologist
Dr. Godfrey Viegas
Dr. Shahid Ilahi
Dr. Joshua Alpert
Centegra Health Systems
Sherman Health

Patient Payment Procedures

It is the responsibility of each patient to know if these services are covered by their insurance. Precertification is also the responsibility of the patient.

If your insurance requires a co-payment or deductible, our Business Office representative will provide you an estimate of that amount prior to surgery. Please be prepared to pay co-payments and/or an estimate of your coinsurance on the day of surgery.

If you have do not have insurance or your insurance does not cover the surgical procedure to be performed, you must make arrangements to pay for your surgery on or before the day it takes place. For your convenience, we accept VISA, MasterCard, Discover, and Care Credit as well as cash and personal checks.

The Business staff at the Algonquin Road Surgery Center will be happy to answer any questions you may have regarding insurance coverage or billing procedures. Feel free to contact the Billing Department at (847) 458-1246