PRIVACY NOTICE
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

This Privacy Notice is being provided to you as a requirement of a federal law, the Health Insurance Portability and Accountability Act (HIPAA). This Privacy Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information in some cases. Your “protected health information” includes all records of your care generated by our facility, including any written and oral health information about you and demographic data that can be used to identify you. This is health information that is created or received by your health care provider, and that relates to your past, present or future physical or mental health or condition.

I. Uses and Disclosures of Protected Health Information
The ASC may use your protected health information for purposes of providing treatment, obtaining payment for treatment and conducting health care operations. Your protected health information may be used or disclosed only for these purposes unless the facility has obtained your authorization or the HIPAA privacy regulations or state law otherwise permits the use or disclosure. Disclosures of your protected health information for the purposes described in this Privacy Notice may be made in writing, orally or by facsimile.

A. Treatment We will use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes the coordination or management of your health care with a third party for treatment purposes. For example, we may disclose your protected health information to a pharmacy to fill a prescription or to a laboratory to order a blood test. We may also disclose protected health information to physicians who may be treating you or consulting with the facility with respect to your care. In some cases, we may also disclose your protected health information to an outside treatment provider for purposes of the treatment activities of the other provider.

B. Payment Your protected health information will be used, as needed, to obtain payment for the services that we provide. This may include certain communications to your health insurance company to get approval for the procedure that we have scheduled. For example, we may need to disclose information to your health insurance company to get prior approval for the surgery. We may also disclose protected health information to your health insurance company to determine whether you are eligible for benefits or whether a particular service is covered under your health plan. In order to get payment for the services we provide to you, we may also need to disclose your protected health information to your health insurance company to demonstrate the medical necessity of the services or, as required by your insurance company, for utilization review. We may also disclose patient information to another provider involved in your care for the other provider’s payment activities. This may include disclosure of demographic information to anesthesia care providers for payment of their services.

C. Operations We may use or disclose your protected health information, as necessary, for our own health care operations to facilitate the function of the ASC and to provide quality care to all patients. Health care operations include such activities as: quality assessment and improvement activities, employee review activities, training programs including those in which students, trainees or practitioners in health care learn under supervision, accreditation, certification, licensing or credentialing activities, review and auditing, including compliance reviews, medical reviews, legal services and maintaining compliance programs, and business management and general administrative activities. In certain situations, we may also disclose patient information to another provider or health plan for their health care operations.

D. Other Uses and Disclosures As part of treatment, payment and health care operations, we may also use or disclose your protected health information for the following purposes: to remind you of your surgery date, to inform you of potential treatment alternatives or options, to inform you of health-related benefits or services that may be of interest to you, to contact you to raise funds for the facility or an institutional foundation related to the facility, or to follow up with you post-operatively. If you do not wish to be contacted regarding fundraising, please contact our Privacy Officer.

II. Uses and Disclosures Beyond Treatment, Payment and Health Care Operations Permitted Without Authorization or Opportunity to Object
Federal privacy rules allow us to use or disclose your protected health information without your permission or authorization for a number of reasons including the following:

A. When Legally Required we will disclose your protected health information when we are required to do so by any federal, state or local law.

B. When There are Risks to Public Health we may disclose your protected health information for the following public activities and purposes:

  • To prevent, control or report disease, injury or disability as permitted by law.
  • To report vital events such as birth or death as permitted or required by law.
  • To conduct public health surveillance, investigations and interventions as permitted or required by law.
  • To collect or report adverse events and product defects, track FDA regulated products, enable product recalls, repairs or replacements to the FDA and to conduct post marketing surveillance.
  • To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease as authorized by law.
  • To report to employer information about an individual who is a member of the workforce as legally permitted or required.

C. To Report Abuse, Neglect or Domestic Violence we may notify government authorities if we believe that a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

D. To Conduct Health Oversight Activities we may disclose your protected health information to a health oversight agency for activities including audits; civil, administrative or criminal investigations, proceedings or actions; inspections; licensure or disciplinary actions; or other activities necessary for appropriate oversight as authorized by law. We will not disclose your health information under this authority if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

E. In Connection With Judicial and Administrative Proceedings we may disclose your protected health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order. In certain circumstances, we may disclose your protected health information in response to a subpoena to the extent authorized by state law if we receive satisfactory assurances that you have been notified of the request or that an effort was made to secure a protective order.

F. For Law Enforcement Purposes we may disclose your protected health information to a law enforcement official for law enforcement purposes as follows:

  • As required by law for reporting of certain types of wounds or physical injuries.
  • Pursuant to court order, court-ordered warrant, subpoena, summons or similar process.
  • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
  • Under certain limited circumstances, when you are the victim of a crime.
  • To a law enforcement official if the facility has a suspicion that your health condition was the result of criminal conduct.
  • In an emergency to report a crime.

G. To Coroners, Funeral Directors and for Organ Donation we may disclose protected health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director as authorized by law in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaver organ, eye or tissue donation purposes.

H. For Research Purposes we may use or disclose your protected health information for research when the use or disclosure for research has been approved by an institutional review board that has reviewed the research proposal and research protocols to address the privacy of your protected health information.

I. In the Event of a Serious Threat to Health or Safety we may, consistent with applicable law and ethical standards of conduct, use or disclose your protected health information if we believe, in good faith, that such use or disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

J. For Specified Government Functions In certain circumstances, federal regulations authorize the facility to use or disclose your protected health information to facilitate specified government functions relating to military and veterans activities, national security and intelligence activities, protective services for the President and others, medical suitability determinations, correctional institutions, and law enforcement custodial situations.

K. For Worker’s Compensation The facility may release your health information to comply with worker’s compensation laws or similar programs.

III. Uses and Disclosures Permitted Without Authorization but with Opportunity to Object
We may disclose your protected health information to your family member or a close personal friend if it is directly relevant to the person’s involvement in your surgery or payment related to your surgery. We can also disclose your information in connection with trying to locate or notify family members or others involved in your care concerning your location, condition or death.

You may object to these disclosures. If you do not object to these disclosures or we can infer from the circumstances that you do not object or we determine, in the exercise of our professional judgment, that it is in your best interests for us to make disclosure of information that is directly relevant to the person’s involvement with your care, we may disclose your protected health information as described.

IV. Uses and Disclosures that require Written Authorization
Other than as stated above, we will not disclose your health information other than with your written authorization. You may revoke your authorization in writing at any time except to the extent that we have taken action in reliance upon the authorization.

V. Your Rights
You have the following rights regarding your health information:

A. The right to inspect and copy your protected health information You may inspect and obtain a copy of your protected health information that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your surgeon and the facility use for making decisions about you.

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or for use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to a law that prohibits access to protected health information. Depending on the circumstances, you may have the right to have a decision to deny access reviewed.

We may deny your request to inspect or copy your protected health information if, in our professional judgment, we determine that the access requested is likely to endanger your life or safety or that of another person, or that it is likely to cause substantial harm to another person referenced within the information. You have the right to request a review of this decision.

To inspect and copy your medical information, you must submit a written request to the Privacy Officer whose contact information is listed on this Privacy Notice. If you request a copy of your information, we may charge you a fee for the costs of copying, mailing or other costs incurred by us in complying with your request.

Please contact our Privacy Officer if you have questions about access to your medical record.

B. The right to request a restriction on uses and disclosures of your protected health information You may ask us not to use or disclose certain parts of your protected health information for the purposes of treatment, payment or health care operations. You may also request that we not disclose your health information to family members or friends who may be involved in your care or for notification purposes as described in this Privacy Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply.

The facility is not required to agree to a restriction that you may request. We will notify you if we deny your request to a restriction. If the facility does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. Under certain circumstances, we may terminate our agreement to a restriction. You may request a restriction by contacting our Privacy Officer.

C. The right to request to receive confidential communications from us by alternative means or at an alternative location You have the right to request that we communicate with you in certain ways. We will accommodate reasonable requests. We may condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not require you to provide an explanation for your request. Requests must be made in writing to our Privacy Officer.

D. The right to request amendments to your protected health information You may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Requests for amendment must be in writing and must be directed to our Privacy Officer. In this written request, you must also provide a reason to support the requested amendments.

E. The right to receive an accounting You have the right to request an accounting of certain disclosures of your protected health information made by the facility. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Privacy Notice. We are also not required to account for any disclosures that you requested, disclosures that you agreed to by signing an authorization form, disclosures for a facility directory, to friends or family members involved in your care or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years. We will provide the first accounting you request during any 12-month period without charge. Subsequent accounting may be subject to a reasonable cost-based fee.

F. The right to obtain a paper copy of this privacy notice Upon request, we will provide a separate paper copy of this notice even if you have already received a copy of the notice or have agreed to accept this notice electronically.

G. The right to restrict disclosures to health insurers You have the right to restrict certain disclosures to health insurers or health plans provided that the services are self paid and the disclosure is not for the purposes of carrying out payment or health care operations, and not required by law.

H. The right to be notified of a breach of unsecured protected health information You have a right to be notified if there is a breach of your unsecured protected health information. In the event of a breach, you will be notified of any impermissible use or disclosure of your protected health information that compromises the security or privacy of that information. All notifications will be issued without unreasonable delay.

VI. Our Duties
The facility is required by law to maintain the privacy of your health information and to provide you with this Privacy Notice of our duties and privacy practices. We are required to abide by the terms of this Notice as they may be amended from time to time. We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all future protected health information that we maintain. If the facility changes its Notice, we will provide a copy of the revised Notice by sending a copy of the revised Notice via regular mail or through in-person contact.

VII. Complaints
You have the right to express complaints to the facility and to the Secretary of Health and Human Services if you believe that your privacy rights have been violated. You may complain to the facility by contacting the facility’s Privacy Officer verbally or in writing, using the information below. We encourage you to express any concerns you may have regarding the privacy of your information. You will not be retaliated against in any way for filing a complaint.

A copy of this Privacy Notice is available on our website at http://www.wentworthsurgerycenter.com or at our office.

Effective Date: January 11, 2017

If you have any questions regarding this notice or your patients rights and responsibilities at Wentworth Surgery Center, please contact the Wentworth Surgery Center Privacy Officer at: (603) 285-9288 or write to:

Wentworth Surgery Center, LLC
6 Works Way
Somersworth, NH 03878
ATTN: Wentworth Surgery Center Privacy officer

WENTWORTH SURGERY CENTER PATIENT BILL OF RIGHTS AND RESPONSIBILITIES
WENTWORTH SURGERY CENTER recognizes your rights while you are choosing to receive medical care at the facility. Please ask to speak to the Administrator if you have any concerns or complaints. Grievance numbers are posted in our waiting room and a full text of the laws pertaining to Patient Rights and Responsibilities, as well as grievance procedures, is available to you, upon request, from the Administration.

  • Patient has the right to be treated with courtesy, consideration, and respect, with appreciation of his or her individual dignity, and with protection of his or her need for personal privacy.
  • Patient has the right to a prompt and reasonable response to questions and requests.
  • Patient has the right to know who is providing medical services, to view their credentials and to know who is responsible for his or her care.
  • Patient has the right to know what patient support services are available, including whether an interpreter is available if he or she does not speak English.
  • Patient has the right to know what rules and regulations apply to his or her conduct.
  • Patient has the right to be given by the health care provider information concerning diagnosis, planned course of treatment, alternatives, risks, prognosis, and how decisions may affect his or her well being.
  • Patient has the right to appropriate assessment and management of pain.
  • Patient has the right to refuse any treatment, except as otherwise provided by law.
  • Patient has the right to free of restraints or seclusion unless they are deemed necessary by the physician to ensure his or her physical safety, and only if no less restrictive intervention is available.
  • Patient has the right to receive care in a safe setting, free from all forms of abuse or harassment.
  • Patient has the right to be given, upon request, full information and necessary counseling on the availability of known financial resources for his or her care.
  • Patient has the right to receive, upon request, prior to treatment, a reasonable estimate of charges for medical care.
  • Patient has the right to receive a copy of a reasonably clear and understandable, itemized bill and, upon request, to have the charges explained.
  • Patient has the right to impartial access to medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment.
  • Patient who is eligible for Medicare has the right to know, upon request and in advance of treatment, whether the healthcare provider or health care facility accepts the Medicare assignment rate.
  • Patient has the right to treatment for any emergency medical condition that will deteriorate from failure to provide treatment.
  • Patient has the right to know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such experimental research.
  • Patient has the right to express grievances regarding any violation of his or her rights, as stated in law, through the grievance procedure of the health care provider or health care facility, which served him or her, and to the appropriate state-licensing agency.
  • Patient has the right to receive a notice of all protected health information practices.
  • Patient has the right to view all protected health information pertaining to him or her.
  • Patient has the right to access an accounting of all disclosures.
  • Patient has the right to request amendments and corrections to personal information they feel is incorrect.
  • Patient has the right to receive confidential communications.
  • Patient has the right to complain to the covered entity and the Department of Health and Human Services.
  • Patient has the right to change their provider if other qualified providers are available.
  • Patient is responsible for providing to the health care provider, to the best of his or her knowledge, accurate and complete information about present complaints, past illnesses, hospitalizations, medications and other matters relating to his or her health.
  • Patient is responsible for being honest in reporting unexpected changes in his or her condition, health status, and medications to the health care provider.
  • Patient is responsible for reporting to the health care provider whether he or she comprehends a contemplated course of action and what is expected of him or her.
  • Patient is responsible for following the treatment plan recommended by the health care provider.
  • Patient is responsible for keeping appointments and, when he or she is unable to do so for any reason, for notifying the health care provider or health care facility.
  • Patient is responsible for his or her actions if he or she refuses treatment or does not follow the health care provider’s instructions.
  • Patient is responsible for assuring that the financial obligations of his or her health care are fulfilled as promptly as possible.
  • Patient is responsible for following health care facility rules and regulations affecting patient care and conduct.
  • Patient is responsible for being respectful at all times towards staff, other patients, visitors, and Wentworth Surgery Center property.

When a Patient is deemed incompetent:

Inform the patient or, as appropriate, the patient’s representative of the patient’s right to make informed decisions regarding the patient’s care.

And a patient is adjudged incompetent under applicable State laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under state law to act on the patient’s behalf.
And a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with State law may exercise the patient’s rights to the extent allowed by State law.

NEW HAMPSHIRE PATIENT BILL OF RIGHTS AND RESPONSIBILITIES
WENTWORTH SURGERY CENTER chooses to recognize your rights and responsibilities, as described in Chapter 151, Section 21 of the State of New Hampshire Patient’s Bill of Rights. Please ask to speak to the Administrator if you have any concerns or complaints.
  • The patient shall be treated with consideration, respect, and full recognition of the patient’s dignity and individuality, including privacy in treatment and personal care and including being informed of the name, licensure status, and staff position of all those with whom the patient has contact, pursuant to RSA 151:3-b.
  • The patient shall be fully informed of a patient’s rights and responsibilities and of all procedures governing patient conduct and responsibilities. This information must be provided orally and in writing before or at admission, except for emergency admissions. Receipt of the information must be acknowledged by the patient in writing. When a patient lacks the capacity to make informed judgments the signing must be by the person legally responsible for the patient.
  • The patient shall be fully informed in writing in language that the patient can understand, before or at the time of admission and as necessary during the patient’s stay, of the facility’s basic per diem rate and of those services included and not included in the basic per diem rate. A statement of services that are not normally covered by Medicare or Medicaid shall also be included in this disclosure.
  • The patient shall be fully informed by a health care provider of his or her medical condition, health care needs, and diagnostic test results, including the manner by which such results will be provided and the expected time interval between testing and receiving results, unless medically inadvisable and so documented in the medical record, and shall be given the opportunity to participate in the planning of his or her total care and medical treatment, to refuse treatment, and to be involved in experimental research upon the patient’s written consent only. For the purposes of this paragraph “health care provider” means any person, corporation, facility, or institution either licensed by this state or otherwise lawfully providing health care services, including, but not limited to, a physician, hospital or other health care facility, dentist, nurse, optometrist, podiatrist, physical therapist, or psychologist, and any officer, employee, or agent of such provider acting in the course and scope of employment or agency related to or supportive of health care services.
  • The patient shall be transferred or discharged after appropriate discharge planning only for medical reasons, for the patient’s welfare or that of other patients, if the facility ceases to operate, or for nonpayment for the patient’s stay, except as prohibited by Title XVIII or XIX of the Social Security Act. No patient shall be involuntarily discharged from a facility because the patient becomes eligible for Medicaid as a source of payment.
  • The patient shall be encouraged and assisted throughout the patient’s stay to exercise the patient’s rights as a patient and citizen. The patient may voice grievances and recommend changes in policies and services to facility staff or outside representatives free from restraint, interference, coercion, discrimination, or reprisal.
  • The patient shall be permitted to manage the patient’s personal financial affairs. If the patient authorizes the facility in writing to assist in this management and the facility so consents, the assistance shall be carried out in accordance with the patient’s rights under this subdivision and in conformance with state law and rules.
  • The patient shall be free from emotional, psychological, sexual and physical abuse and from exploitation, neglect, corporal punishment and involuntary seclusion.
  • The patient shall be free from chemical and physical restraints except when they are authorized in writing by a physician for a specific and limited time necessary to protect the patient or others from injury. In an emergency, restraints may be authorized by the designated professional staff member in order to protect the patient or others from injury. The staff member must promptly report such action to the physician and document same in the medical records.
  • The patient shall be ensured confidential treatment of all information contained in the patient’s personal and clinical record, including that stored in an automatic data bank, and the patient’s written consent shall be required for the release of information to anyone not otherwise authorized by law to receive it. Medical information contained in the medical records at any facility licensed under this chapter shall be deemed to be the property of the patient. The patient shall be entitled to a copy of such records upon request. The charge for the copying of a patient’s medical records shall not exceed $15 for the first 30 pages or $.50 per page, whichever is greater; provided, that copies of filmed records such as radiograms, x-rays, and sonograms shall be copied at a reasonable cost.
  • The patient shall not be required to perform services for the facility. Where appropriate for therapeutic or diversional purposes and agreed to by the patient, such services may be included in a plan of care and treatment.
  • The patient shall be free to communicate with, associate with, and meet privately with anyone, including family and resident groups, unless to do so would infringe upon the rights of other patients. The patient may send and receive unopened personal mail. The patient has the right to have regular access to the unmonitored use of a telephone.
  • The patient shall be free to participate in activities of any social, religious, and community groups, unless to do so would infringe upon the rights of other patients.
  • The patient shall be free to retain and use personal clothing and possessions as space permits, provided it does not infringe on the rights of other patients.
  • The patient shall be entitled to privacy for visits and, if married, to share a room with his or her spouse if both are patients in the same facility and where both patients consent, unless it is medically contraindicated and so documented by a physician. The patient has the right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, including choice of room and roommate, except when the health and safety of the individual or other patients would be endangered.
  • The patient shall not be denied appropriate care on the basis of race, religion, color, national origin, sex, age, disability, marital status, or source of payment, nor shall any such care be denied on account of the patient’s sexual orientation.
  • The patient shall be entitled to be treated by the patient’s physician of choice, subject to reasonable rules and regulations of the facility regarding the facility’s credentialing process.
  • The patient shall be entitled to have the patient’s parents, if a minor, or spouse, or next of kin, or a personal representative, if an adult, visit the facility, without restriction, if the patient is considered terminally ill by the physician responsible for the patient’s care.
  • The patient shall be entitled to receive representatives of approved organizations as provided in RSA 151:28.
  • The patient shall not be denied admission to the facility based on Medicaid as a source of payment when there is an available space in the facility.
  • Subject to the terms and conditions of the patient’s insurance plan, the patient shall have access to any provider in his or her insurance plan network and referral to a provider or facility within such network shall not be unreasonably withheld pursuant to RSA 420-J:8, XIV.

Source. 1981, 453:1. 1989, 43:1. 1990, 18:1-6; 140:2, XI. 1991, 365:10. 1992, 78:1. 1997, 108:6; 331:3-8. 1998, 199:2; 388:5, 6. 2001, 85:1, eff. Aug. 18, 2001. 2009, 252:1, eff. Sept. 14, 2009. 2013, 265:3, eff. Jan. 1, 2014; eff Jan. 11, 2017.

FINANCIAL DISCLOSURE

FINANCIAL DISCLOSURE

For billing purposes, there are several healthcare practitioners who are providing a service to you. These charges will be billed to your insurance company separately. Therefore, you may receive bills from multiple providers for one procedure at Wentworth Surgery Center.

  • Facility Charge – Wentworth Surgery Center will bill for the facility fee only

  • Physician’s Professional Charge – Your Physician will bill your insurance company for the Physician fees

  • Anesthesia Professional Charge – The anesthesia provider will bill your insurance company for the Anesthesia fees

  • Pathology Charge – If a biopsy is taken during the procedure, you will receive a bill from the laboratory(s) that processes your biopsy

Wentworth Surgery Center will bill your procedure to your insurance company(s) for the facility portion, but ultimately, you are responsible for charges applied to your copay, deductible and co-insurance. Some insurance carriers may deny or choose not to cover services that are provided and you will become financially responsible for these charges. We recommend that you contact your insurance carrier for coverage information regarding your individual insurance policy.

Our Insurance Verification Specialist will contact you twice prior to your procedure. You will first be contacted with an estimate for the facility charges once your procedure is scheduled. Then, the day prior to procedure, you will receive a call to collect your financial responsibility, based on your individual insurance policy. It is important to know that this is only an estimate. This estimate is based on the procedure(s) your physician has scheduled and the insurance plan you have. Once the claim has been processed by your insurance, you may receive a bill and/or phone call for the remaining balance owed or a refund if you have overpaid.

Please be advised that you will not receive a call the day prior to your procedure if we do not expect you to have a patient responsibility.

PRIVATE PAY

Private Pay

Please contact Wentworth Surgery Center, in advance, if you are paying with cash, check or credit card. Arrangements for payment must be made prior to the date of your procedure.

Payments and/or deductibles are due prior to the time services are rendered.

WSC Self-Pay Waiver Form

Patient Name: _____________________________________

Patient Account ID: ________________________________

Date of Service: ____________________________________

PATIENT WAIVER AND AGREEMENT FOR SELF-PAYMENT

I, _________________________________________, have chosen to self-pay for health care services provided at Wentworth Surgery Center, LLC. I have decided to self-pay, if even I may have health insurance that covers these services. Furthermore, I agree to waive my right to have a claim submitted to my insurance company on my behalf.

The costs associated with my procedure(s) at Wentworth Surgery Center, LLC are as outlined in my financial agreement.

My signature below indicates that I have received a copy of this document and that I am aware that I am waiving my right to have a claim submitted to my insurance company. Payment is due in full at the time services are rendered.

___________________________________________ ________________________________

Signature                                                                          Date

MEDICARE / MEDICAID

Medicare/ Medicaid

Wentworth Surgery Center is a licensed Medicare and Medicaid Provider. We bill Medicare or Medicaid directly for the fees associated with your care. As a beneficiary of Medicare or Medicaid, you are responsible for all deductibles and co-insurance.

INSURANCE

Insurance

Insurance is a contract between you and your insurance company. Wentworth Surgery Center is not a party to your contract. We will not become involved in disputes between you are your insurance company regarding deductibles, non-covered charges, co-insurance payments, secondary insurance and coordination of benefits or pre-existing conditions other than that to provide factual information, as needed.

 

You, the patient is responsible for deductibles, co-insurance payments and co-pays. Additionally, any medical care determined by your insurance company to be a “non-covered benefit” is also your responsibility. It is very important that you notify us of any changes to your insurance coverage. Incorrect information could mean delays in payment from your insurance company.

 

Aetna

Anthem NH/MA

Cigna

Coventry

Harvard Pilgrim

Humana

Maine Community Health Options

Martin’s Point

Generation Advantage

US Family Health

Medicaid

Medicare

NH Healthy Families

Multiplan

Tricare

Tufts

United Healthcare

USA Managed Care

Well Sense Health Plan

Worker’s Compensation Insurance Claims

And more…


Accreditation / Membership Affiliation & Affiliates

Nothing found within this website should be construed as medical advice or treatment recommendations by WSC. This information is not a substitute for a consultation for any symptoms that you may have. Note that you should consult your physician for medical advice.
In the case of bad weather the facility will remain open unless the governor shuts down the state or the facility does not have power.

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