Advanced Technology Lens Disclosure and Consent Form

ADVANCED TECHNOLOGY INTRAOCULAR LENS DISCLOSURE AND CONSENT FORM

The purpose of this notice is to help you make an informed choice about whether you want to receive these items or services. Insurance does not cover Advanced Technology Intraocular Lenses. You are financially responsible for any copayments, coinsurance, and deductibles as well as any non-covered items and services

After determining if you are a good candidate for an advanced technology intraocular lens (IOL), your doctor may recommend one to you, but ultimately the decision to opt for an advanced technology IOL is yours. Based on the information provided on the cataract consent form and given the different IOL options available to you the decision is yours to make; it is optional. The major difference between cataract surgery with a traditional IOL versus cataract surgery with an advanced technology IOL is the degree of dependence on eyeglasses thereafter. Implantation of advanced technology IOL does not guarantee that you will be 100% free from glasses.
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The undersigned accepts full financial responsibility for the services described and selected above.
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Important Notice: Physician Ownership Disclosure

Please take a moment to review the following information.

1. The Surgery Center of Des Moines - West is a physician-owned ambulatory surgery center. Partial minority ownership is held by: Hammer, Ball, Steffensmeier, Raecker, Blodi, along with other physicians from the Des Moines metro.

2. You have the right to choose where you receive your healthcare services. While we believe that the Surgery Center of Des Moines - West can provide the care you need, you are free to select a different facility that your physician performs surgery at without any impact on your relationship with your physician.

For questions regarding this notice, please don't hesitate to ask a representative from Surgery Center of Des Moines - West. We value and appreciate your trust.

Iowa ASC Referral Disclosures

Ambulatory surgery centers (ASCs) differ from hospitals in ownership, licensing, certifications, accreditation, and payment methods, though both meet high standards and follow specific regulations. Medical staff and anesthesia standards at ASCs match those in hospitals. ASCs have emergency transfer agreements in place and complies fully with anesthesia regulations.

By signing, you, or your legal representative, acknowledge that you have read and understand this notice. This disclosure has been provided before your procedure, and you have chosen to proceed with your procedure at Surgery Center of Des Moines - West
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5901 Westown Parkway, Suite 200, West Des Moines, IA 50266
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Payment for Advanced Technology Lenses will be collected ~ 1 week prior to surgery.
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