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: 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 THIS FORM MAY 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 Ascent Emergency Medical Center, LLC.) to order all necessary tests and treatments while I am a patient at Ascent Emergency Medical Center, LLC. 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 to take photographs, should the need arise, for purpose of my treatment during my health evaluation and treatment.

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.

 PRIVACY NOTICE ACKNOWLEDGEMENT

 A copy of 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, SARS-CoV-2, HIV or Hepatitis, to determine the presence of any communicable disease for the benefit of the exposed employee. I understand that these test results may only become a part of my medical record if it is required to report such results in order to comply with state law.  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 & vape-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, LLC., 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.

 ASSIGNMENT OF INSURANCE BENEFITS

 I assign Ascent Emergency Medical Center, LLC., 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, LLC., and/or physicians/healthcare providers thereof. This assignment is made in accordance with §1204.054, Tex. Ins. Code.

I also assign and transfer to Ascent Emergency Medical Center, LLC. 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, LLC.

 Ascent Emergency Medical Center, LLC. 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.

Ascent Emergency Medical Center, LLC. is NOT a participating Medicare or Medicaid provider. Medicare / Medicaid beneficiaries will be charged the time-of-service fee schedule for prompt-pay patients for any treatment or services rendered during length of stay at this facility. ADVANCED NOTIFICATION: Ascent Emergency Medical Center will not file a claim to Medicare or Medicaid.  Medicare and Medicaid recipients may be personally responsible to Ascent Emergency Medical Center for charges incurred while receiving treatment or care at Ascent Emergency Medical Center.

 Ascent Emergency Medical Center, LLC. Is an “out-of-network” provider with all insurance and/or health benefit plans. 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 physicians (Drew Emergency Physicians, PLLC, consulting physicians), or healthcare providers rendering services to me while at Ascent Emergency Medical Center, LLC. 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 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. 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 patient balances. Acceptable means of payments are cash, money order, cashier’s check, credit card, or personal checks. I further understand that if I am evaluated by a physician other than the attending emergency room physician that I may be billed for those physician services.

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: (713) 821-2360.

NON-COVERED SERVICES

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

 ACKNOWLEDGEMENT AND SIGNATURE

 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 the HIPAA notice and HB2041 Disclosure has been made available to me.

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.

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 Administrator at (713) 574-1166.

Presentation of a complaint shall not compromise care. If your complaint or grievance is not resolved to your satisfaction, you may contact the Texas Department of State Health Services, Health Facility Compliance Group (MC 1979) PO Box 149347, Austin, TX 78714-9347 TDSHS/HHS 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.