I hereby attest that all information I have provided is true and correct.

I attest that all information provided here is true and correct to the best of my knowledge.

Insurance Information

This facility is a freestanding emergency medical care facility.

This facility charges rates comparable to a hospital emergency room and may charge a facility fee for medical treatment.

A facility or a physician providing medical care at the facility may be an out-of-network provider for the patient's health benefit plan provider network.

The physician providing medical care at this facility may bill separately from the facility for the medical care provided to a patient.

This facility is an out-of-network provider for all health benefit plans.

You may view our fee schedule and a complete list of charges at:
https://ascentemc.com/list-of-charges/

I, the undersigned, have read and understand this notice. 

HB2041 Registration Disclosure AEMC v2 02.2022

NOTICE TO PATIENT/GUARANTOR: THE ASCENT EMERGENCY MEDICAL CENTER IS A LICENSED FREESTANDING EMERGENCY CARE CENTER. YOUR INSURANCE WILL BE BILLED FOR EMERGENCY ROOM SERVICES AND PHYSICIAN SERVICES. A COPY OF THESE FORMS CAN BE MADE AVAILABLE TO THE PATIENT.

CONSENT TO TREATMENT

I consent to the procedures that may be performed during this visit including emergency treatment and/or services which may include, but are not limited to, laboratory services, x-ray examinations, diagnostic procedures, physician, nursing, or services rendered to me as ordered by my physician or other health care professional. I voluntarily request and consent for independently contracted physicians (via Drew Emergency Physicians, PLLC.) to order all necessary tests and treatments while I am a patient at Ascent Emergency Medical Center, I understand that medical care is not an exact science and that no guarantee or warrantee is being made as to my examination, treatment, result, or outcome. I understand that I am free to withdraw my consent and to discontinue participation in these procedures at any time. However, I understand that doing so may hinder my treatment and/or medical outcome.

CONSENT TO USE AND DISCLOSE INFORMATION

I agree and consent to the use and disclose of my health information for the purpose of treatment, payment from third party payers, and other healthcare operations, such as the maintenance of medical records, communication of health information with primary care physician, referring physician or other healthcare professionals who contribute to my care, including quality peer reviews and assessments. I grant permission for Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC. to take photographs, should the need arise, for the purpose of my treatment
during my health evaluation and treatment.

NOTICE OF DATA COLLECTION

The Texas Department of State Health Services Texas Healthcare Information Collection (THCIC) program will receive patient claim data regarding services provided by Ascent Emergency Medical Center and Drew Emergency Physicians. The patient’s claim data is used to help improve the health of Texans through various methods of research and analysis. Patient confidentiality is held to the highest standard and your information is not subject to public release. THCIC follows strict internal and external guidelines as outlined in Chapter 108 of the Texas Health and Safety Code and the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

DIVORCED PARENTS OF MINOR PATIENTS

By signing below, the adult who signs in a minor child to our facility on the day of service accepts full responsibility for payment and will be listed on the account as the Guarantor. It is not our policy to send bills or records to the other parent/guardian for issue of payment or communication. We will communicate about treatment and payment with the parent present with the patient at the facility. Parents are responsible for communicating with each other about treatment and payment issues.

 PRIVACY NOTICE ACKNOWLEDGEMENT

A copy of the Notice of Privacy Practices has been made available to me as required by the Health Insurance Portability and Accountability Act. I understand that if I have questions or complaints, I may contact our corporate office.

 ACCIDENTAL BODILY FLUID EXPOSURE TO HEALTHCARE WORKER

In the case of my bodily fluid exposure to a healthcare employee, I consent to testing, which may include, but not limited to, HIV or Hepatitis, to determine the presence of any communicable disease for the benefit of the exposed employee. I understand that these test results do not become a part of my medical record. I understand that I will be responsible for the charges for any such test.

 SMOKING POLICY

To maintain the health and safety of patients, visitors, and staff, Ascent Emergency Medical Center is a strictly enforced smoke-free environment. Ascent Emergency Medical Center and its associated entities are not responsible for any claim or harm arising from smoking, or from leaving the facility for the purpose of smoking or consuming tobacco products including e-cigarettes and vaping devices.

 PERSONAL VALUABLES

Although the facility will make all reasonable efforts in safeguarding my valuables, I understand that Ascent Emergency Medical Center is not responsible for the loss or damage of personal valuables.

LEGAL RELATIONSHIP BETWEEN EMERGENCY ROOM AND PHYSICIANS

I am aware that my doctor may have an ownership interest in Ascent Emergency Medical Center and that I have a right to seek medical treatment elsewhere. A list of physician owners may be obtained upon request by the patient or legal guardian.

ASSIGMENT OF INSURANCE BENEFITS

I assign Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC. all right, title, and interest in any and all health insurance and/or health plan proceeds/benefits from any plan(s) arising from the provision of any goods and services provided by Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC. and/or physicians/healthcare providers thereof. This assignment is made in accordance with §1204.054, Tex. Ins. Code.

I further assign and transfer to Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC. all rights, title, and interest in any claims against any health insurers, sponsors and/or plan administrators of any of my health benefit plan(s) arising from or pertaining to any wrongful acts and/or omission pertaining to any of said health/benefit plan(s) or health insurance policy(ies) including, but not limited to, claims for a non-payment or underpayment of health provider invoices and claims. I further expressly and knowingly assign all rights under my benefit plan and the Employee Retirement Income Security Act of 1974 to sue my benefit plan for any breach of its fiduciary duty. By executing this assignment of benefits, I am directing the health insurance carrier or other health benefit plan providing my coverage (including, but not limited to, any employers, employer group, or trust sponsored or offered plan), to pay Ascent Emergency Medical Center and Drew Emergency Physicians, PLLC., and any consultant physician services for which may be billed on my behalf.

Ascent Emergency Medical Center, and Drew Emergency Physicians, PLLC. file primary and secondary insurance claims for insured patients. I authorize the facility and/or physicians indicated above to release medical information about me as may be necessary for the completion of my insurance claims for this occasion of service to any insurance carrier or health plan.

FINANCIAL AGREEMENT AND PATIENT GUARANTEE

Ascent Emergency Medical Center is NOT a participating Medicare, Tricare, or Medicaid provider. Medicare, Tricare or Medicaid beneficiaries will be charged in accordance with the facility’s prompt-pay fee schedule. Ascent Emergency Medical Center will not file a claim to Medicare, Tricare or Medicaid. Medicare, Tricare and Medicaid recipients may be personally responsible to Ascent Emergency Medical Center and Drew Emergency
Physicians, PLLC. for payment.

Ascent Emergency Medical Center is an “out-of-network” provider with all insurance and/or health benefit plan. I understand that my out-of-network payment responsibility may be higher than an in-network option. Texas Insurance Law states that if a condition is deemed a medical emergency, insurance will pay in accordance with the plan’s benefits of the services at the “in-network” benefit level, but not all emergency room services are medical emergencies. I understand that my facility bill is inclusive of laboratory and radiology services provided to me during my length of stay. I understand that if a consulting physician is used during the course of treatment rendered to me that I will be duly informed and will be responsible for any charges incurred for such consultation physician services. In accordance with the No Surprise Act requirement the beneficiary or guarantor will not be balanced billed for any amounts which are considered not allowable by your insurance company. The guarantor or beneficiary will only be billed for co-pays, deductibles and co-insurance amounts in accordance with the insurance plan.

I understand that physicians or healthcare providers rendering services to me while at Ascent Emergency Medical Center may bill separately. I understand that physicians or healthcare providers providing services while at Ascent Emergency Medical Center may not be participating providers with the same third-party payers or benefit plans. I understand that I am responsible for paying all providers subject to the terms of my health plan or insurance, if any.

I agree, whether signing as agent or a patient, that in consideration of the services to be rendered, I hereby am responsible for paying facility copayments, deductibles, estimated facility coinsurance amounts, and any balances deemed not to be a covered benefit of the insurance policy. These payments may be due AT TIME OF SERVICE. Monthly statements will be sent to guarantors for account balances. Acceptable means of payments are cash, money order, cashier’s check, credit card, or personal checks. I further understand that during my length of stay if I am evaluated by a physician other than the attending emergency room physician that I may be billed for those physician services.
Unless prior arrangements are made, prompt-pay balances must be paid in full prior to discharge. If the balance due is referred to a collection agency or attorney, I understand that there may be additional fees, interest, and expenses that I will be responsible. Questions regarding your bill may be directed to: Wise Staff Billing at (346) 304-6871.

NON-COVERED SERVICES

If any of the provided services are not covered by my insurance company, or if Ascent Emergency Medical Center or Drew Emergency Physicians, PLLC. is not able to verify eligibility, I am responsible for all charges incurred for services rendered.

 

Patient Rights

The physicians, nurses, and entire staff are committed to assure  you safe, reasonable care. 

1. A patient has the right, upon request, to be given the name of his attending practitioner, the names of all other practitioners directly participating in their care and the names and functions of other healthcare professionals having direct contact with the patient. 

2.   A patient has the right to consideration of privacy concerning their own medical care program. Case discussions, consultation, examination, and treatment are considered confidential and shall be conducted discreetly.

3. A patient has the right to have records pertaining to their medical care treated as confidential, except as otherwise provided by law or third-party contractual arrangement.   

4. A patient has the right to know what facility rules and regulations apply to his conduct as a patient.

5. A patient has the right to expect emergency procedures to be implemented without necessary delay.

6. The patient has the right to good quality care and high professional standards that are continually maintained and reviewed.

7. The patient has the right to full information in layman’s terms; concerning diagnosis, treatment & prognosis, including information about alternative treatments and possible complications. When it is not medically advisable to give the information to the patient, the information shall be given on their behalf to their designee.

8. Except in emergencies, the practitioner shall obtain the necessary informed consent prior to the start of a procedure. Informed consent is defined in Texas Administrative Code, Title 25, Part 7m Chapter 601.

9. A patient, or if the patient is unable to give informed consent, a responsible person, has the right to be advised when a practitioner is considering the patient as part of a medical research program or donor program, and the patient, or responsible person, shall give informed consent prior to actual participation in the program. A patient, or responsible person, may refuse to continue in a program to which he has previously given consent.

10. A patient has the right to refuse drugs or procedures, to the extent permitted by statute, and a practitioner shall inform the patient of the medical consequences of the patent’s refusal of said drugs or procedures.

11. A participant has the right to medical and nursing services without discrimination based upon age, race, color, religion, sexual orientation, national origin, handicap, disability or ability to make payment.

12. The patient who does not speak English should have access, where possible, to an interpreter.

13. The facility shall provide the patient, or patient designee, upon request, access to information contained in their medical records unless access is specifically restricted by the attending practitioner for medical reasons.

14. The patient has the right to expect good management techniques to be implemented with the facility. Those techniques shall make effective use of the time of the patient and avoid the personal discomfort of the patient.

15. When an emergency occurs and a patient is transferred to a hospital, the responsible person/patient’s designee shall be notified. The institution to which the patient is to be transferred shall be notified prior to the patient’s transfer.

16. The patient has the right to expect the facility to provide information for continuing health care requirements following discharge and the means for meeting them.

17. A patient has the right to be informed of his rights at the time of admission.

18. The facility expects the patient to ask questions about any directions or procedure they do not understand.

19. The facility expects the patient to be considerate of other patients and staff in regard to noise, smoking, and number of visitors in the patient areas. The patient is also expected to respect the property of the facility and other persons.

20. The patient is expected to follow instructions and medical orders and report unexpected changes in their condition to their physician and facility staff.

21. The patient is expected to follow all safety regulations that they are told or read about.

22. If the patient fails to follow their healthcare provider’s instructions, or if the patient refuses care, they are responsible for their own actions.

23. The patient has the right to ask the ER to honor their Advanced Directive.

24. The patient has the right to be free from all forms of abuse, neglect, exploitation, or harassment.

PATIENT RESPONSIBLITIES

As a patient you are responsible for:

1. Providing, to the best of your knowledge, true and accurate information about present complaints, past illnesses, hospitalizations, medications, and other matters related to health.
2. Sharing expectations. Patients should provide the organization with information about their expectations of and satisfaction with the organization.
3. Asking questions. Patients should ask questions when they do not understand their care, treatment or services or what they are expected to do.
4. Following instructions. Patients should follow their plan of care, treatment or services. They should also express any concerns about their ability to follow the proposed plan of care, treatment or services.
5. Accepting consequences. Patients should accept their share of responsibility for the outcomes of care, treatment or services if they do not follow the care, treatment or services plan.
6. Following policies and procedures. Patients should follow the organization's policies and procedures. 
7. Showing respect and consideration. Patients should be considerate of the organization's staff and property, as well as other patients and their property.
8. Meeting financial commitments. Patients should meet any financial obligation agreed to with the organization.

I have read, understand, and accept the consents, policies, and terms as set forth above. All above information provided is true to the best of my knowledge.

A copy of my patient rights and HIPAA have been made available to me. I understand that I am entitled to a copy of this form upon request.

Should you have a complaint or grievance please contact the facility administrator. Presentation of a complaint shall not compromise care. If your complaint or grievance is not resolved to your satisfaction or to report abuse, you may contact the Texas Department of Health and Human Services, Health Facility Compliance Group (MC 1979), PO Box 149347, Austin, TX 78714-9347 or the TDHHS Complaint Hotline: (888) 973-0022.

 Your Rights and Protection Against Surprise Medical Bills

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.

What is "balance billing" (sometimes called "surprise billings")?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. “Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. “Surprise billing” is an unexpected balance bill. This can happen when you cannot control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.

You are protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

In accordance with the No Surprise Act requirement the beneficiary or guarantor receiving services at Ascent Emergency Medical Center will not be balanced billed for any amounts which are considered not allowable by your insurance company. The guarantor or beneficiary will only be billed for co-pays, deductibles and co-insurance amounts in accordance with the insurance plan.

Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.

This facility is in compliance with HB2041. This information is provided to you in a separate disclosure. This facility does not balance bill for any out-of-network services.

When balance billing isn’t allowed, you also have the following protections:

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly. Your health plan generally must:

• 
  Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.

If you believe you’ve been wrongly billed, you may contact Texas Health and Human Services at (800) 458-9848 or email hfc.complaints@hhs.texas.gov

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law. For more information about your rights under Texas state laws visit:
https://www.tdi.texas.gov/tips/texas-protects-consumers-from-surprise-medical-bills.html 

I, the undersigned, have read and understand this notice.

I hereby acknowledge that I am a prudent layperson (possessing an average knowledge of medicine and health) and have significant concern that I am potentially suffering from an emergency medical condition and failure to get immediate medical care could result in:

1. Severe pain / distress;

2. Placing my health in serious jeopardy;

3. Serious impairment of bodily functions;

4. Serious dysfunction of a bodily organ or part;

5. Serious disfigurement; or

6. In the case of pregnancy, serious jeopardy to the health of the fetus.

V1 02.2023