Associated Surgeons & Physicians, LLC (ASAP)

NOTICE OF FINANCIAL INTEREST IN HEALTH CARE ENTITY

The undersigned individual is hereby notified by his/her treating/referring physician (the “Physician”), who is associated with Associated Surgeons and Physicians, LLC (“ASAP”) that, by virtue of the Physician’s association with ASAP, the Physician may have part-ownership or a financial interest in one of the hospitals within the Lutheran Network or the IU Ambulatory Surgery Center (“ASC”).  The Physician believes the Hospital or ASC is an appropriate setting for the medical care and services for which the undersigned is being referred.  Nevertheless, the selection of a specific health care entity/facility always rests with the patient, and as such, the undersigned may choose to be referred to an alternate entity/facility of his/her choice.  The undersigned hereby acknowledges and certifies that he/she has received a copy of the Notice of Financial Interest in Health Care Entity.

CONSENT FOR TREATMENT OF ADULT

I (the patient) hereby consent to the administration of health care (including care, treatment, services, examinations, tests, consultations or procedures to maintain, diagnose or treat me (the patient) by ASAP. This Consent for Treatment shall specifically include tests for the presence/absence of alcohol or controlled substances. By my signature below, I acknowledge that I am giving my consent to the administration of health care by ASAP voluntarily, and that I hereby knowingly and voluntarily enter into this Consent for Treatment. I have been informed and acknowledge that I may withdraw my consent hereunder at any time upon written notice to ASAP.

CONSENT FOR TREATMENT OF MINOR

I am the (circle one) parent/guardian/custodian/legally authorized representative/other an un-emancipated minor child who is years of age ("Patient") and I have authority to execute this Consent for Treatment on behalf of the Patient. I hereby consent to the administration of health care (including care, treatment, services, examinations, tests, consultations or procedures to maintain, diagnose or treat the patient's condition) by ASAP for the Patient. The conditions or limitations, if any, on my consent and the authority delegated to ASAP hereunder include:. The consent for Treatment shall specifically include tests for the presence/absence of alcohol or controlled substances. By my signature below, I acknowledge that I am giving my consent to the administration of health care by ASAP for the Patient voluntarily, and that I hereby knowingly and voluntarily enter into the Consent for Treatment. Due to the Patient's inability to legally sign this Consent for Treatment, I hereby agree on behalf of the Patient, to sign forthe Patient, and to bind the patient to the terms of this Consent for Treatment. I have been informed and acknowledge that I may withdraw my consent hereunder at any time upon written notice to ASAP.

AGREEMENT TO PAY

I agree that I am responsible for payment for all services provided to me by ASAP, subject to limitations set forth in any applicable insurance or otherthird-partyapplicable insurance agree agree payco-paymentspay other outstanding balances for which I am responsible. Specifically, I will be responsible for any services: which Medicare, Medicaid, Medigap or my insurance or other third-party benefits plan determines are not covered; for which the benefits have been exhausted; for which I fail to obtain any required authorization from my primary care physician; and, for which any spend down amount has not been met. I will also be responsible for any out-of-network fees and for any other amounts which are due and are not required to be written off by the contract ASAP has with my insurance or other third-party benefits carrier. I agree to pay such amounts within 30 days of being notified by ASAP of the balance due. / understand that if / fail to pay my balance, my account may be turned over to a collection agency or attorney. In such an event, / agree that / will be responsible for a collection fee equal to 30% of my balance (or reasonable attorney fees) including interest and court costs.

ASSIGNMENT OF BENEFITS

I hereby assign to ASAP all rights I have to be reimbursed for medical expenses generated by ASAP with respect to Medicare, Medicaid, Medigap and/or any other insurance carrier, including any plan or policy of insurance (group or individual), flexible spending account, health savings account, health reimbursement arrangement or similar plan or reimbursement mechanism. This assignment includes all rights that I may have under ERISA, including but not limited to all rights concerning obtaining copies of plan/policy documents, rights to reasonable and customary fee schedules, and rights to appeal any full or partial claim denial for treatment by ASAP. In addition, I hereby request that payment of any authorized Medicare benefits, Medicaid benefits, Medigap benefits and or/insurance or other third party benefits be made directly to ASAP. If said benefits are not paid directly to ASAP, I agree to forward to ASAP all payments that I receive immediately upon my receipt. To assist in this process, I authorize any holder of medical information about me to release to CMS, my Medigap insurer, Indiana health Coverage Programs/Medicaid and/or any other insurance or third-party payor and their respective agents any information needed to determine the benefits payable for the services rendered to me.

ACKNOWLEDGEMENT AND RELEASE

I hereby authorize ASAP and all physicians and providers involved with my care to release information from my medical records as may be required to any person, corporation, or agency which is legally responsible or which ASAP has good cause to believe is legally responsible, for processing and/or paying all or any part of ASAP charges and/or professional fees; and, to any entity which has contracted with any insurer to conduct utilization or performance review. I hereby authorize ASAP and any affiliated physician or provider involved with my care to release information to any physician or provider to which I may be transferred for further medical care.

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

I have been offered the opportunity by ASAP to receive a copy of the Notice of Privacy Practices.