Financial Assistance Policy

SURGERY CENTER OF WESTON, LLC. (the ‘Facility’)

Financial Assistance, Payment Plans, Discounts, Charity Care Policy and Collection Procedures

It is the policy of the Facility to collect all copayments, coinsurances, and deductibles at or before the time of service. As well, the Facility will inform patients that they may request an estimate of charges for a scheduled procedure, what financial assistance may be available and how to apply.

Florida law requires the Facility to notify the patient or prospective patient that:

1. 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.

2. The patient or prospective patient may or may not pay less for the services being provided at another facility or in another health care setting. Please know that the attending physician who scheduled the patient’s procedure(s) at the Facility may or may not be on the medical staff of other such facilities.

The Facility does not employ its own physicians. Each physician or provider of service will bill separately for his/her services and follows his/her own billing and collection procedures. There are no providers, other than the Facility itself, delivering medically necessary services in the Facility who are covered under this policy.

If Facility believes that you have health insurance and/or HMO coverage(s) that may cover some or all of the Services, Facility may initiate contact with them to determine your cost-sharing responsibilities for Facility’s’ bill. You may contact them directly as well for additional information concerning your cost-sharing responsibilities. If Facility determines that you have cost-sharing responsibilities for Facility’s bill, in accordance with Facility’s financial assistance policies, you will be required to pay your cost-sharing responsibilities in full on or before Services are provided. The Facility’s financial assistance policies are that if you are unable to pay your cost-sharing responsibilities in full on or before Services are provided, because you believe you are medically indigent, or you are not covered by any health insurance or HMO, upon request, the Facility, in its sole discretion, may offer you a discount on the amount due and/or offer a payment plan. Any such discount is considered by Facility to be “charity care.” There is no formal application process for obtaining “charity care” at Facility.

Facility’s standard collection policy is to produce and send one or more bills to patients for their cost sharing amounts, which if not paid on a timely basis, may then be placed with an attorney or collection agency to pursue such unpaid amounts. If accounts are placed with an attorney and/or collection agency, the costs charged by the attorney and/or collection agency will be passed onto the patient to pay, and the patients’ credit score may be negatively impacted.

In accordance with Florida law, upon verbal or written request the Facility will provide the patient in writing or by electronic means a good faith estimate of Facility’s anticipated gross charges based on the patient’s procedure(s) as indicated by the physician/surgeon to treat the patient’s condition within seven (7) business days of the request (if a patient is insured, the contracted insurance rates will supersede the gross charges estimate).

As with any medical procedure, if unforeseen circumstances should arise during the procedure it may be necessary for the physician to perform additional or different procedures and/or to use more/less expensive supplies or implants. The use of implants and/or the difference in procedures may cause the estimate to vary significantly.

However, it is understood that final gross charges and patient responsibility will depend on actual services provided and may or may not exceed the original estimate.

The estimate of charges being provided to the patient is for the Facility only. If the patient would like a written estimate from other health care providers who will provide services at the Facility, he/she should contact each health care provider as well as asking if they participate as a network provider or preferred provider for that patient or prospective patient’s individual health maintenance organization (insurance company).