LEGAL RELATIONSHIP BETWEEN SURGERY CENTER AND PHYSICIANS: I understand that all physicians furnishing services to the patient, including the patient’s physician, and any specialist such as an anesthesia provider, radiologist, or pathologist are independent contractors with the patient and are not employees or agents of the surgery center. The patient is under the care and supervision of his/her physician and it is the responsibility of the surgery center and its staff to carry out instructions of the physician. It is the responsibility of the patient’s physician to obtain the patient’s consent, when required, to medical or surgical treatment or procedures. Any questions concerning the nature or results of an examination or treatment should be directed to the patient’s physician and not to the surgery center employees.

OTHER PROFESSIONAL SERVICES: I understand that my physician may have a professional radiology service review radiological images. My physician may also send specimens to a professional pathology laboratory for a pathological diagnosis. Radiology and pathology services are billed separately by those individual physicians and laboratories.

PERSONAL VALUABLES: It is agreed and understood that the surgery center shall not be responsible for any personal property brought by the patient to the surgery center, including but not limited to money, jewelry, documents, or any other articles.

OWNERSHIP OF SURGERY CENTER: I understand that my physician may be an owner of this surgery center. I understand that I am free to choose another facility in which to receive the services that have been ordered by my physician.

ADVANCED DIRECTIVE/LIVING WILL: I understand The Orthopedic and Sports Surgery Center is an outpatient surgery center that is limited to elective surgery only and performs no high-risk surgical procedures. Therefore, this surgery center will not acknowledge advanced directives of any patient while in the surgery center. In the event of an emergency the patient will be stabilized and transferred to a hospital as soon as possible. The surgery center can provide you with a copy of advanced directives if you wish to complete them and have them in place in the event you are transferred to the hospital, where the advanced directives will be honored.

FINANCIAL AGREEMENT: I agree that, to the extent necessary to determine liability for payment and to obtain reimbursement, the surgery center may disclose portions of my financial and/or medical records to any person or entity which is or may be liable for all or any portion of the charges (including but not limited to insurance companies, health care service plans, or workers compensation carriers). I agree that in consideration of the services rendered, I shall be individually responsible to pay the surgery center for all such services, should my insurance company deny payment. I shall also be responsible for any co-payments owed at the time of services. I have received and agree to the Patient Financial Policy stating the payment options for any remaining self-pay balance on my account. The Surgery Center will file a claim with my current medical insurance and I authorize the payment of medical benefits to the surgery center for the services provided.

PATIENT PRIVACY, RIGHTS AND RESPONSIBILITIES: I have been offered a copy of the Privacy Notice and the Patient Rights and Responsibilities. I am aware that at any time I have the right to file a grievance with the Director of Quality, the Wisconsin Division of Quality Assurance, and/or The Office of the Medicare Beneficiary Ombudsmen.

You will be asked to sign this form to verify your understanding of the above information when you register for surgery.