CENTER FOR SURGICAL DERMATOLOGY & CENTER FOR SURGICAL DERMATOLGY AMBULATORY SURGERY CENTER Patient Medical History NAME:
DATE: SEX: M F
DATE OF BIRTH:
REFERRED BY:
Reason for Today’s visit: PAST MEDICAL HISTORY: ALLERGIES: Are there medications or other items to which you have had an allergic reaction or unpleasant side effect? Yes No If yes, please list these items below and describe the side effect: 1.
3.
2.
4.
MEDICATIONS: Please list any prescription and non-prescription medications including pain relievers you are currently taking. Please include medication name and dosage. If you are taking more medications than space provides, please continue on a separate sheet of paper.
Medication
Dosage
Frequency
Medication
Dosage
Frequency
CHRONIC DISEASES AND SURGERIES Please list any chronic diseases, major illnesses and surgeries you have had: 1.
5.
2.
6.
3.
7.
4.
8.
Do you have:
defibrillator
artificial joints take coumadin? yes - date of last INR
no
PERSONAL/SOCIAL HISTORY Do you wear:
dentures
glasses
contact lenses
Smoking:
no
former
yes, packs per day:
Alcohol:
no
social/occasional drinking only
hearing aids
daily, drinks per day:
Alcohol or drug problems/addictions: no yes. If yes, please describe: Pharmacy Name: ___________________________________
Phone # (
) __________________________________
Pharmacy Street: ___________________________________
City: ______________________ Zip code: __________
May we obtain a history of prescriptions directly from your pharmacy? Yes No Rev. 2-2017
CENTER FOR SURGICAL DERMATOLOGY & CENTER FOR SURGICAL DERMATOLGY AMBULATORY SURGERY CENTER Patient Medical History PATIENT NAME:
DOB:
PAST MEDICAL HISTORY/FAMILY HISTORY AND REVIEW OF SYSTEMS Please check the boxes below if you or anyone in your immediate family has the following conditions: (if other please note in box below) Skin Melanoma Basal/Squamous # of Cancers ______ Pre-Cancer Abnormal Scarring Plastic Surgery Changing Moles Other: Neurological Stroke Seizures Other:
Self
Family
Hematologic/Lymphatic Anemia Bleeding problems Enlarged Lymph Nodes Other: Respiratory Emphysema Shortness of Breath Other:
Self
Family
Cardiovascular Angina (chest pain) Artificial Valve Irregular Heart Rhythm Pacemaker Hypertension Heart Attack AICD (Defibrillator)
Self
Family
Other:
Constitutional Unexplained Weight Loss
Endocrine Diabetes Thyroid Kidney Disease
Fever Other:
Other: Infections Hepatitis HIV/AIDS
Stomach Ulcer Colitis Liver Disease Other:
Gastrointestinal
Increased Risk for AIDS
Tuberculosis (TB) Productive Cough Weight Loss Night Sweats Exposure Other:
Eyes/Ears/Nose/Throat Glaucoma Plastic Surgery Other:
Musculoskeletal Arthritis Artificial Joint Have you fallen in the past 30 days? Yes No Do you use a wheelchair or ambulatory aids? Yes No Type: __________________ Psychiatric Depression Anxiety Attacks Personality Disorder Other: Cancer (Non-Skin) Please list:
Patient Signature
Date
Form reviewed and verified (please sign and date for each appointment): CSD Employee Sign Here CSD ASC Employee Sign Here Name (Signature)
Date
Physician Initials
Name (Signature)
Date
Name (Signature)
Date
Physician Initials
Name (Signature)
Date
Name (Signature)
Date
Physician Initials
Name (Signature)
Date
DDDDDDDDD Name (Signature)
Date
Physician Initials
Name (Signature)
Date Rev. 2-2017
CENTER FOR SURGICAL DERMATOLOGY & CENTER FOR SURGICAL DERMATOLOGY AMBULATORY SURGERY CENTER Patient Demographics (Please print) Patient’s Name:
Name I Preferred to be Called:
Home Address: City:
State:
Home Phone: _______________________________
E-mail:
Cell Phone: ________________________________
May we send you information via e-mail regarding cosmetic specials? Yes No
Work Phone: _______________________________ Date of Birth: Race:
Social Security #:
African American
Marital Status:
Zip:
American Indian
Married Widow/Widower
Single Divorced
Asian Sex:
Caucasian Male
Hispanic Female
Employer: ________________________________________ Occupation: _________________________ Employer Address: City:
State:
Zip:
Spouse’s Name if applicable:
Date of Birth:
Emergency Contact: Phone Number:
Relationship:
How were you referred to our office? Physician RSVP Mailer Skin Cancer Screening
Ad in Suburban News Family
Friend Self
Primary Care Physician:
Referring Physician:
Address:
Address:
City: Phone Number:
State:
Zip:
City:
Yellow Pages Other
State:
Zip:
Phone Number:
1 Created 8/18/2011
Patient Name: Name:
Date of Birth: Fiscally Responsible Party Information (If Other Than Patient)
Home Address: City:
State:
Home Phone:
Home E-mail:
Zip:
Insurance Information Is a referral required for this appointment? Yes No Primary Insurance: Policy #:
Group #:
Relationship to Patient:
Self
Spouse
Domestic Partner
Parent
If subscriber other than patient, please complete the following information: Subscriber Name: Home Address: City:
State:
Date of Birth:
Social Security#
Zip:
Secondary Insurance (If Applicable) Secondary Insurance: Policy #: Relationship to Patient:
Group#: Self
Spouse
Domestic Partner
Parent
Subscriber Name (if other than patient): Date of Birth: _______________________________ Social Security# ______________________________ I certify that as the patient or responsible party I assign all insurance benefits to the Center for Surgical Dermatology (CSD) and/or Center for Surgical Dermatology Ambulatory Surgery Center (CSD ASC) and its physicians otherwise payable to me. I understand and agree that I am financially responsible for all charges whether or not paid by my insurance. My signature further authorizes CSD/CSD ASC to release information necessary to obtain payment of benefits. Signature of Patient (or Responsible Party & Relationship to Patient)
Date
Q:Forms/CSD/Patient Demographics 2 Created 10/16/2008
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Q:Forms/CSD ASC/Forms to Use/Patient Privacy Instructions CSD ASD 6/08
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B R I AN P. B I ER NAT , M.D. P ET ER C. S ELI NE , M.D. ANGELA S. CASEY, M.D.
L I ND A S. R U P ER T , M.D. B R A D LEY S. S O D ER , M.D. D EEP A C. L I NGA M , M.D. N A ND A C HA N NA I A H , D.O J A M ES S A N F I LLI P O , M.D.
MOHS MICROGRAPHIC SURGERY What is Mohs surgery? - A skin cancer removal technique that offers the highest cure rate. This technique allows the doctor to remove the least possible amount of healthy tissue while still removing all the cancer. - This technique is usually used for skin cancers which: o are located in areas where a greater amount of healthy tissue needs to be preserved (ie. eyes, nose, ears, hairline, hands, etc). o have a high risk for recurrence or have recurred with previous treatment. o have borders that are not well defined and/or have other skin cancers in close proximity. o are large in size. - A Mohs surgeon is specially trained in surgery, pathology, and reconstruction. What can I expect the day of surgery? - Please arrive 15 minutes early with completed paperwork, photo ID, and insurance/Medicare cards. - The area will be numbed with local anesthesia. The visible tumor will be removed along with a layer of the surrounding tissue. - The tissue will be processed in our lab which typically takes around one hour. You will wait in the waiting room during this time. - Once the tissue is ready, the doctor will examine the tissue under the microscope. - If cancer remains, another layer of tissue will be removed. This process will be repeated until the entire tumor is removed. The average number of tissue layers removed is 2 to 3. - When the tumor is completely removed, the doctor will discuss with you the best options for closing the wound. - Because it is unknown how many times the doctor will need to take tissue, it is impossible to predict how long your surgery will last. It may only take several hours, but be prepared to spend the entire day with us. - We request that you do NOT schedule any other appointments for the day of surgery. - Bring books, magazines, or another activity to help pass your time. We do have Wi-Fi available for your use. Is there food available? - We recommend you bring your lunch with you. We do have a refrigerator in which we can store cold items from your lunch. There are also vending machines available with beverages and limited snack items. - We do not have a coffee machine. If you want coffee, please bring it with you. Diabetics, continue to take your medication. Follow your regular meal schedule by bringing snacks and your lunch. **CONTINUED**
Should I bring a driver? - If the surgical site is anywhere near your eye, the final dressing may limit or occlude your vision. - If you are feeling very anxious, we can give a medication to help calm your nerves called Valium; however, in order to be given Valium a driver is required. - If you are unsure if you need a driver, it is always better to have one with you or have someone on standby if the need arises. Are there any medications that would affect my surgery? ** The morning of surgery, take all prescribed medications. Eat a regular breakfast and also bring any medications you will need to take throughout the day. ** - Unless otherwise instructed by your prescribing physician, continue taking all prescribed medications. This includes Plavix, Coumadin, Pradaxa, Aspirin, or any other similar blood thinners. - If you take over the counter non-prescription medications or herbals that thin the blood, such as: Ibuprofen, Advil, Aleve, Motrin, Vitamin E, Excedrin, Anacin, Bufferin, ginko biloba, ginseng, ginger, Fish Oil, and/or Aspirin not prescribed by a physician- stop these 7-10 days before surgery. Tylenol or Acetaminophen can be used during this time for pain. - Alcohol also thins the blood, if possible please discontinue 7-10 days prior to surgery. If you are on Oxygen- you are responsible to bring enough oxygen to last for the entire day. We do not have a supply of oxygen for patient use. Smoking will slow healing time and increase chance of complications- stop or greatly decrease the number of cigarettes smoked for 5 days before surgery and for 2 weeks after surgery. What can I expect after surgery? - You will leave with a large, bulky dressing called a pressure bandage. This will need to remain in place for 24 hours. - You should not participate in any strenuous activity for at least one week after surgery. This includes: working out, running, sports (even golf and yoga), heavy lifting, yard work and shoveling snow. By doing these activities, it is possible you may bleed under your stitches which leads to complications. If you have a question about an activity you have planned, please ask! - Flying in an airplane can complicate your recovery and we request at least 48 hours after surgery before airplane travel. - Expect bruising and/or swelling. The amount varies person to person and usually lasts for a week or longer. Activity level will greatly contribute to the amount of bruising and swelling. - We will discuss with you and also send home a detailed instruction sheet about the care of your surgical site. If you have any further questions, please call our office at 614-847-4100 ext. 122 or visit our website; www.centerforsurgicaldermatology.com. If in need of a hotel, we have been given reduced rates at nearby hotels. Please call our office for a list of these hotels or visit the website listed above. Q:/Forms/CSD/MMS handout 4-2014
Phone (614) 847-4100 Fax (614) 430-1601
428 County Line Road West Westerville, OH 43082-7027
CSD / ASC BILLING POLICY Dear Patient: We are committed to providing you with the best possible care. With health care policy constantly changing, we do not have the ability we once did to know if you are approved for your visit. We wish to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our financial policy. 1. Your insurance is a contract between you and the insurance company. We are not a party to that contract. 2. We are contracted with many insurance companies and if you have a question regarding whether or not we are an in network provider with your plan, please contact your insurance company. In order to be able to file your insurance claims, we must have a copy of your insurance cards as well as a picture I.D. We will submit to your primary and secondary insurances. If there is a change in your insurance plan coverage or if you receive a new or updated card, please notify us as soon as possible. Without this information, we may be unable to submit your claim to your insurance for payment. 3. Because our providers are specialists, some insurance companies require a referral from your primary care physician (referring physician). These can be faxed to us at 614-761-0849. If this is not done prior to your appointment, you will be asked to either reschedule your appointment and contact your PCP, or pay for the services at the time you are seen. Any payments made at the time of service will be promptly refunded upon receipt of payment by the insurance company. 4. CSD has 11 providers including 8 physicians and 3 nurse practitioners (NP). All of our NP's are board certified and have subspecialty training in dermatology. **NP billing: Please note that your bill following a visit with a NP may or may not show the name of that practitioner. More commonly it will show the name of one of our CSD physicians, and it may or may not be one you have seen before. Which provider gets listed is determined by your insurance company rules (third-party carrier or Medicare) and not by us. This is often a confusing point so please keep it in mind. 5. Your visit will generate up to three (3) separate bills. Depending on what surgery, if any, you need to have done, you will receive statements from the following: a. Center for Surgical Dermatology, Inc: This is the fee our practice, CSD, charges for performing the surgery. If you have any questions regarding this bill, feel free to call (614) 339-1360. b. The Center for Surgical Dermatology Ambulatory Surgery Center (CSD ASC): This is the fee for the use of the surgery facility which includes, for example, costs for your pre-operative and post-operative care, nursing care, the Operating Room Suite, nursing care while in surgery, medical equipment used, any supplies used in surgery such as sutures, ace bandages/wraps, etc., and the costs associated for the overall facility. CSD ASC bills by the procedures that are performed, NOT by the amount of time you are in surgery. If you have any questions about this bill, feel free to call (614) 339-1360. c. Pathology charges: We are required by the state of Ohio to explain to patients the method of billing, including charges for pathology services. If your provider performs a biopsy or excision, your specimen will be sent to a Board Certified Dermatopathologist (skin pathologist) for interpretation whenever possible. The Center for Surgical Dermatology/Dermatology Associates (CSD and its providers) maintain contracts with multiple pathology labs to insure the highest quality of patient care and also to accommodate as many of our patients’ insurance companies as possible. In most cases, preparation of the skin biopsy for the pathologist is done in the Center for Surgical Dermatology Pathology lab. You are billed for the preparation work from CSD ($90) and billed for the physician’s reading from the outside pathology lab. If the skin pathologist requires additional studies on your
CSD/ASC Billing Policy Page 2
tissue (special stains, immunochemistries) to help with making your diagnosis, those will appear on their bill whether to your insurance company or you. Occasionally the pathology work is subcontracted. The amount CSD is charged for this service ranges from $30.00 - $38.00. When CSD is able to bill your insurance directly or you directly instead of the pathology company doing the billing, we (CSD) can bill it for somewhat less than the approximate $110.00 - $170.00 the pathology company would normally charge for the service. Please note that this policy applies to only some insurances. d. Many insurance policies carry differing levels of coverage for in-network and out-of-network physicians. Again, you must clarify with your insurance that our physicians are an in network provider with your particular plan. It is also your responsibility to contact your insurance company prior to your procedure to clarify your own benefit levels, copays, deductibles, etc. as you are primarily responsible for the charges. 6. Certain payments are due at the time when services are rendered including copays, outstanding balances, cosmetic procedures or products. We accept cash, personal checks, Visa, MasterCard, Discover and American Express. 7. If you do not have insurance, please call the billing office as soon as possible. Billing representatives are available MondayFriday 7:30 am to 4:30 pm at 614-339-1360 to answer any questions related to the above or to set up a payment plan if necessary. We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate such problems so that we can assist you in the management of your account. 8. Cancellation Policy: As a courtesy to our other patients, please call at least 24 hours in advance to cancel or reschedule your appointments. We are pleased to have you as our patient. Your assistance as well as your patience with the above issues is appreciated as this will help make your overall visit with us go very smoothly. If you have any questions, please feel free to contact our office. I HAVE READ THE ABOVE FINANCIAL ARRANGEMENTS AND INSURANCE STATEMENT AND I REALIZE THAT PAYMENT IS MY OBLIGATION FOR COVERED AND NON-COVERED SERVICES REGARDLESS OF INSURANCE OR THIRD PARTY INVOLVEMENT. I AUTHORIZE THE PHYSICIAN TO FURNISH MY INSURANCE COMPANY WITH ANY INFORMATION REQUIRED AND MY INSURANCE BENEFITS TO BE PAID TO THE PHYSICIAN. ____________________________________ Patient (Guarantor) Signature
___________________________________ Patient Name Printed
____________________________________ Patient DOB
___________________________________ Date
Q:Forms/ASC CSD / FORMS TO USE /Billing Policy CSD ASC Updated 10/15/2013
AMBULATORY SURGERY CENTER
Acknowledgement Form for Patient or their Surrogate or Representative
□
I have been provided with the policy summary on Advanced Directives for the Center for Surgical Dermatology ASC (CSD ASC). I am aware I may contact you if I desire additional information on how to obtain State of Ohio Advance Directive forms.
I do have Advance Directives in place If Yes, type:
□ Yes □ No
□ □ □
Living Will
□
I have been advised to bring a copy with me to my appointment
Durable Power of Attorney for Healthcare (POA) Other _______________________
□
I am aware that my surgeon is one of a group of surgeons (Drs. Biernat, Seline, Casey) who have ownership in CSD ASC. I am aware that I am free to choose another facility in which to receive the services that have been ordered by my physician.
□
I hereby acknowledge that I have been provided copies of the Patient Rights and the Patient Responsibilities handouts from the Center for Surgical Dermatology ASC. (CSD ASC).
________________________________ Signature
________________________________________ Date Time (If signed day of surgery)
________________________________ Printed Name
________________________________________ Date of Birth
Q:\forms\CSDASC\formstouse\acknowledgementform 11-13
428 County Line Road West Westerville, OH 43082-7027 (614) 847-4100 Fax (614) 430-1604
AMBULATORY SURGERY CENTER
Dear patient, You will soon be seeing one of our surgeons for the evaluation and management of a skin cancer at the Center for Surgical Dermatology. The consultation and removal will be performed in the procedure rooms in the doctor’s office. In most cases, some level of reconstruction (surgery to repair the wound where the cancer was) is necessary. That is often done in the adjacent Ambulatory Surgery Center. In order to have your visit proceed as efficiently as possible, we need your assistance in reviewing and completing the forms included in this packet. We are obligated by law to provide you with some of this information. We request you complete the enclosed forms before your initial visit and bring them with you to your appointment. Included in the packet are the following: -Demographics form (personal and insurance information) -Medical history form -Billing Policy -Patient's Rights -Summary Acknowledgement Form -Advanced Directives -Map -HIPAA form In addition, if you are scheduled for Mohs surgery, you will receive a Mohs Micrographic Surgery information form and Frequently Asked Questions handout. If you have a Power of Attorney/Advance Directive form currently in effect, please bring that with you. We are pleased to have you as our patient. Your assistance as well as your help with the above issues is appreciated as this will help make your overall visit with us go very smoothly. If you have any questions, please feel free to contact our office. Respectfully, Medical Director CSD Ambulatory Surgery Center Q:\forms\CSDASC\formstouse\ASCpatientletterprevisit 11/2013
428 County Line Road West Suite 100 Westerville, OH 43082-7027 (614) 847-4100 Fax (614) 430-1604
AMBULATORY SURGERY CENTER
Information Sheet about the Ambulatory Surgery Center What is an Ambulatory Surgery Center (ASC)? It is a surgical facility where outpatient surgeries are performed. The patients do not require hospitalization. ASC’s are accredited and certified by both state and federal agencies to ensure the environment in them creates the safest possible surgical setting. Even though the Center for Surgical Dermatology ASC is located in the same building as our office practice, they are separate businesses as required by law. Most insurance companies including Medicare approve surgeries to be done in the ASC’s because:
It is the best environment for their insured patients, which is most evident through the lowered rate of infections. It is less costly than Outpatient Hospital Surgery Centers The physician reimbursement is generally less if performed in the ASC rather than if done in a private office. However, this creates both physician charges and ASC facility charges.
Our billing staff checks, prior to surgery, with each patient’s insurance to clarify their eligibility for the ASC. Some insurance policies have deductibles for both the office visit and the ASC Surgery Center. Patients are responsible for both deductibles if that is the case. Almost all of the insurance companies we work with approve surgeries in our ASC but please check with your insurance to see what your coverage and/or deductible will be. Most but not all reconstructions are done in the Surgery Center. The type of reconstruction needing to be done and the individual insurance companies approval helps us decide if the surgery is appropriate for reconstruction in the ASC or if it is done in the office side of the practice.
The Center for Surgical Dermatology ASC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Q:Forms:CSD ASC:Forms to use:ASC information sheet
428 County Line Road West Westerville, OH 43082-7027 (614) 847-4100 Fax (614) 430-1604
10-2016
Center for Surgical Dermatology Ambulatory Surgery Center PATIENT* RIGHTS Patients *(and their representatives or surrogates) at the Center for Surgical Dermatology ASC have the right to: 1. Treatment without regard to age; gender; race; cultural, economic, educational, religious background; disability or the source of payment for care. 2. Considerate, respectful and dignified care from competent personnel in a safe environment. 3. The patient has the right to be free from all forms of abuse or harrassment. 4. The patient has the right to be free from any act of discrimination or reprisal. 5. The knowledge of the name of the physician who has primary responsibility for coordinating care and the names and professional relationships of other physicians who will see them. 6. Receive information from their physician about their illness, their course of treatment, and their prospects for recovery in terms they can understand. When it is medically inadvisable to give such information to the patient, the information is provided to a person designated by the patient or to a legally authorized person. 7. Communicate with Center staff and employees in the language or manner they are
accustomed to. Reasonable attempts will be made to accommodate such as the need arises. 8. Have access to information contained in the patient’s medical record, within the limits of state law, by each patient or patient’s designated representative. 9. Privacy and security of self and belongings during the delivery of patient care service. 10.Be fully informed about any proposed treatment or procedure and the expected outcome before it is performed; 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 in this treatment, alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who would carry out the treatment or procedure. 11.Participate actively in decisions regarding their medical care. To the extent permitted by law, this includes the right to refuse treatment. If they are incapable of making medical decisions, according to state law, an approved patient representative will act on their behalf. 12. Full consideration of privacy concerning their medical care program. Case discussion, consultation, examination and treatment are confidential and shall be conducted discreetly. The patient has the right to be advised as to the reason for the presence of any individual. 13.Confidential treatment of all communications and records pertaining to their care. Their written permission shall be obtained before their medical records are made available to anyone not concerned with their care. 14.Reasonable responses to any reasonable request they make for services.
15.Reasonable continuity of care and to know in advance the time and location of appointments as well as the physician providing the care. 16.Be advised if the physician proposes to engage in or perform research affecting their care or treatment. The patient has the right to refuse to participate in such research projects. 17.Be informed by their physician or designee of their continuing health care requirements. 18.Examine and receive an explanation of their bill regardless of source of payment. 19.Have all patient's rights explained to the person who has legal responsibility to make decisions regarding medical care on behalf of the patient. 20.Express any grievances or suggestions (verbally or in writing) regarding treatment or care that is (or fails to be) furnished. 21.The patient is free to change providers at their discretion. 22.In the event of a patient complaint, the Nurse Administrator, Business Administrator, and/or Medical Director shall be notified immediately by the clinical staff. The Nurse Administrator, Business Administrator or Medical Director shall respond to complaints either in person or by telephone interview with the patient/legal guardian within 24 hours. After investigation and review, the Nurse Administrator, Business Administrator or Medical Director shall respond to the patient either by telephone followup, or if necessary, in writing within thirty (30) days of the complaint. 23. Any person having a complaint pertaining to the care rendered a patient shall be advised of their right to direct the complaint in writing to: Ohio Department of Health Provider and Consumer Services Unit 246 North High Street Columbus, OH 43215 Or by telephone: 1-800-342-0553 The person making the complaint shall be contacted by the Department of Health. The person may also contact the Office of the Medicare Beneficiary Ombudsman at the following website: http://www.medicare.gov/claims-and-appeals/medicare-rights/gethelp/ombudsman.html The role of the Medicare Beneficiary Ombudsman is to help Medicare beneficiaries receive information and understand their Medicare rights. Q:\forms\csdasc\formstouse\ASCpatientrights 12-2016
AMBULATORY SURGERY CENTER
Advance Directives
Advance Directives are documents or documentation that you can complete prior to becoming ill allowing you to give direction about future medical care or to designate/choose another person(s) to make medical decisions if you can no longer do so.
In Ohio, living wills, durable power of attorney for health care (POA) and declaration for mental health treatment are recognized as valid Advance Directives. Also, federal law requires that all facilities that participate in Medicare/Medicaid must advise patients of their right to address treatment issues through Advance Directives.
The Center for Surgical Dermatology ASC (CSD ASC) performs elective, “low risk” procedures. It is very unlikely that our patients would have a medical emergency while being treated at our Center. In the event this were to occur, it would likely be something that was reversible. Therefore, we would take efforts to correct the problem and if necessary, you would be transported to the hospital. At the hospital, further treatments or the withdrawal of treatment measures will be exercised in accordance with your Advance Directive or POA. If you disagree with this policy, please address this issue with your physician prior to your scheduled procedure.
Durable Power of Attorney for Healthcare (POA) is honored at our Center.
Should you wish to obtain State of Ohio Advance Directive forms, CSD ASC will provide you these forms upon request. They may also be obtained at http://www.midwestcarealliance.org/aws/LAO/asset_manager/get_file/116093/choices_6th_edition_lao_version. pdf Q:\forms\CSDASC\formstouse\advancedirectives 2016
428 County Line Road West Westerville, OH 43082-7027 (614) 847-4100 Fax (614) 430-1604
Center for Surgical Dermatology Ambulatory Surgery Center PATIENT RESPONSIBILITIES As a patient of the Center for Surgical Dermatology Ambulatory Surgery Center (CSD ASC), you have the following responsibilities: 1. Show respect and be courteous to other patients, family, visitors and personnel of CSD ASC. 2. Understand that we do our best to accommodate your needs and the needs of other patients. 3. Provide CSD ASC with an accurate and complete medical history about present complaints, past illnesses, hospitalization, surgeries, medications (including over the counter products and dietary supplements), allergies or sensitivities, and other pertinent data to the best of your knowledge. 4. Provide accurate and complete demographic and insurance information including change of address. 5. Assure that the financial obligations for health care rendered are paid. 6. Accept consequences of your actions if you refuse a treatment or procedure. 7. Ask questions, particularly when you do not understand directions, procedures or other information given by your doctor or health care team member. 8. Follow the plan of treatment recommended by the doctor primarily responsible for your care and/or other personnel authorized by the center to instruct patients. 9. Keep your appointment. If you anticipate a delay or must cancel the scheduled procedure, it is your responsibility to notify us as soon as possible. 10. Carry out preoperative instructions, if applicable, as supplied by your physician or CSD ASC. 11. Have available a responsible adult to transport you home from the facility and remain with you for twenty-four (24) hours, if required by your provider. 12. Inform CSD ASC about any living will, medical power of attorney, or other directives that would affect your care.
Q:\Forms\CSD ASC\FORMS TO USE\ASC Patient Responsibilities.doc
12/10
Office of Civil Rights Notice of Non-discrimination Source: HHS Office for Civil Rights Center for Surgical Dermatology ASC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Center for Surgical Dermatology ASC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Center for Surgical Dermatology ASC: • Provides free aids and services to people with disabilities to communicate effectively with us, such as: ◦ Qualified sign language interpreters ◦ Written information and other formats (large print, audio, accessible electronic formats) • Provides free language services to people whose primary language is not English, such as: ◦ Qualified interpreters ◦ Information written in other languages If you need the services, contact- Ronald Siegle MD, Civil Rights Coordinator. If you believe that Center for Surgical Dermatology ASC has failed to provide the services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Center for Surgical Dermatology ASC Civil Rights Coordinator: Ronald Siegle MD 428 County Line Rd. W. Westerville, OH 43082 614-847-4100 614-430-1604
[email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Ronald Siegle MD, is available to help you. You can also file a civil rights complaint with the US Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: US Department of Health and Human Services 200 Independence Ave. SW Room 509F, HHH building Washington, DC 20201 Toll-free: 1-800-868-1019, 1-800-537-7697 TDD. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Ronald J. Siegle, M.D. Brian P. Biernat, M.D. Peter C. Seline, M.D. Angela S. Casey, M.D.
Linda S. Rupert, M.D. Bradley S. Soder, M.D. Deepa Lingam, M.D. Nanda Channaiah, D.O. James San Filippo, M.D.
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ton Rd. Orion Pl.
Maxtown Rd.
161
We are located north and east of the I-71 & I-270 Interchange about 15 miles north of downtown Columbus. land
Powell Road
3
Sun b ur
315
614-430-1601
Cleve
750
614-847-4100
P k w y.
270
428 County Line Road West Westerville, Ohio 43082-7027 TEL :
Polar is
Cleveland Ave.
750
hi n g
N
i Pl. min
Wo r t
It’s easy to find the Center for Surgical Dermatology & Dermatology Associates
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Ge
71
161
FROM THE NORTH, exit I-71 at Gemini Place/Polaris Parkway and turn left (East) at the light. Cross over the highway and turn right (South) on Orion Place to Polaris Parkway (0.3 miles). Turn left (East) on Polaris Parkway and go one mile to Cleveland Avenue. Turn right (South) on Cleveland Avenue and go 1/2 mile. Turn left (East) on County Line Road West. Immediately turn left on Alkyre Run Drive and turn right into our parking lot. FROM THE SOUTH, you have two options.
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270
315
• The most direct would be to exit I-270 at Cleveland Avenue and go North 2 miles. Turn right on County Line Road West and take the immediate first left onto Alkyre Run Drive and turn right into our parking lot.
670
70 70 33
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• A second option is to stay on I-71 north until Polaris Parkway. Turn right (East) on Polaris Parkway to Cleveland Avenue (Just over 1 mile). Turn right and go 1/2 mile south on Cleveland Avenue. Turn left on County Line Road West. Immediately turn left on Alkyre Run Drive and turn right into our parking lot. If you are coming from the north side of Franklin County or southern Delaware County it may be helpful to know that Powell Road (Route 750) coming from the west is continuous with Polaris Parkway which as you go east is continuous with Maxtown Road.
CALL US IF YOU NEED DIRECTIONS. 614-847-4100
Specializing in Mohs Surgery • Skin Cancer Treatment • Dermatologic and Cosmetic Surgery • Liposuction • Laser Surgery • • Sclerotherapy • Skin Rejuvenation • Skin Care Products •
