FLORIDA HEALTH FINDER
Patients may access the State of Florida’s Agency for Healthcare Administration website at this link for information about this surgery center: www.floridahealthfinder.gov.
PATIENT RESOURCES ON DEFINED SERVICE BUNDLES AND PROCEDURES
Information on payments made to the facility for defined bundles of services and procedures is available at http://pricing.floridahealthfinder.gov/. The service bundle information is a non-personalized estimate of costs that may be incurred by the patient for anticipated services, and actual costs will be based on services actually provided to the patient.
PERSONALIZED ESTIMATE OF CHARGES
Upon a patient’s request, DSC and health care providers can provide a more personalized estimate of charges and other information prior to the service; including patients with no insurance. Please note that the payments and payment ranges are an estimate of the cost that may be incurred and your actual cost may vary based on actual services rendered. You may pay less for this procedure or service at another facility or in another health care setting. 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.
Patients and prospective patients may request from this facility and other health care providers a more personalized estimate of charges and other information. Patients and prospective patients should contact each health care practitioner who will provide services in the ASC to determine the health insurers and health maintenance organizations with which the health care practitioner participates as a network provider or preferred provider. Please see the providers tab on our website for more information on the providers that render services at DSC.
FINANCIAL ASSISTANCE POLICY
Charity care or financial assistance is not offered to patients at this time. If you do not have insurance, you are responsible for the payment of all services and fees. You will need to arrange payment with all entities separately.
STATEMENT OF FINANCIAL RESPONSIBILITY
In consideration of medical treatment and services provided to the above named patient, the undersigned unconditionally guarantees payment of the account charges and balance in full to DSC at discharge of the patient. DSC will process verified and assigned insurance claims as a courtesy to the patient.
COLLECTION POLICY, PAYMENTS AND PROCEDURES
All uninsured balances or amounts remain payable at discharge. A late payment charge of 1.5% per month (18% per annum) will be charged on any unpaid balance not paid within 60 days of the procedure you receive at DSC. DSC’s efforts to collect insurance proceeds do not affect the patient/undersigned’s responsibility for any account balance. If DSC finds it necessary to refer this account for collection to enforce the obligation of the patient and/or the undersigned party(ies), the patient and/or undersigned agrees to pay any and all additional collection expenses, including DSC’s reasonable Attorney’s fee. The proper venue for any legal action shall be in Polk County, Florida.