To help expedite your check-in process, you may upload a copy of your insurance card at this time (optional). On a mobile device you can simply snap a photo of your card. On a desktop, you can upload a scanned copy. 

INSURANCE CLAIMS
Your medical insurance is a contract between you and your insurance carrier and it is your responsibility to provide current and accurate insurance information and to understand your insurance benefits. On your behalf, the Center will submit all claims for our services with your insurance providers. If your insurance company does not submit payment, you are liable for your account balance. It is your responsibility to contact your insurance company with any coverage questions, and to respond to any inquiries from them in a timely manner regarding your condition or procedure.

INSURANCE PAYMENTS
If you receive payment for our claim directly from your insurance company, you agree to forward the payment to the Center within 7 business days. Withholding the insurance payment may eliminate insurance write-offs and may incur additional legal and collection expenses.

CO-PAYMENTS, DEDUCTIBLES, NON-COVERED SERVICES AND SELF PAY
Co-payments, deductible amounts, and estimated balance of co-insurance may be due on or before the day of surgery. If you have no medical insurance, choose not to use your benefits, or request a service that is not covered by your insurance policy, payment for services are expected prior to your procedure.

PATIENT BALANCE
Account balances after insurance processing may be made by check, cash, money order, Visa, MasterCard, American Express, Discover and Care Credit. Any patient balance not settled in full within 30 days of the first statement may be subject to a $20/month rebilling fee. Please call our business office if you need to make payment arrangements at 503-688-5180.

ADDITIONAL BILLS
Wilshire Surgery Center bills for the facility fee only, and you should expect separate bills from your surgeon, anesthesia provider, and possibly your lab. The policies stated here relate only to the facility fee. Please contact your other providers for their billing policies.

MINORS
A parent or legal guardian must accompany a minor and consent to treatment, unless otherwise stipulated by law. Parents or legal guardians must comply with the terms of this billing policy. The parent or guardian that accompanies the minor will be held responsible for payment of services should any dispute over payment arise.

 

By signing below, you are acknowledging that you have read and understand our Patient Financial Policies. A copy will be sent to your email address upon completion of the registration process.

State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below.

It is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.

You may request a copy of our Privacy Notice at any time by contacting our Privacy Office or Administrator. Information on contacting us can be found at the end of this Notice.

TYPICAL USES AND DISCLOSURES OF HEALTH INFORMATION

We will keep your health information confidential, using it only for the following purposes:

Treatment: We may use your health information to provide you with our professional services. We have established “minimum necessary or need to know” standards that limit various staff members’ access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.

Disclosure: We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so. If you have paid out of pocket in full, you may request that we not share information about your treatment with your health plan. If you are a Medicare beneficiary paying for a covered service out of pocket, we will restrict the disclosure of your information regarding this service to Medicare.

Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.

Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. If at all possible we will provide you with an opportunity to object to this use or disclosure. Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care. We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.

Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.

Required by Law: We may use or disclose your health information when we are required to do so by law (court or administrative orders, subpoena, discovery request or other lawful process). We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary, to prevent a serious threat to your health or safety or that of others.

Public Health Responsibilities: We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.

National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards or letters.

YOUR PRIVACY RIGHTS AS OUR PATIENT

Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. If you wish to examine your health information, you will need to complete and submit an appropriate request form. Contact our Privacy Officer for a copy of the Request Form. You may also request access by sending us a letter to the address at the end of this Notice. Once approved, an appointment can be made to review your records. Copies, if requested, will be $1.00 per page for the first 100 pages and $.25 per page thereafter, plus a $10 search fee per request. You may request a copy in electronic record format. If you want the copies mailed to you, postage will also be charged. If you prefer a summary or an explanation of your health information, we will provide it for a fee. Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.

Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.

Non-routine Disclosures: You have the right to receive a list of non-routine disclosures we have made of your health care information. (When we make a routine disclosure of your information to a professional for treatment and/or payment purposes, we do not keep a record of routine disclosures: therefore these are not available.) You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations. You can request non-routine disclosures going back 6 years.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We do not have to agree to these additional restrictions, but if we do, we will abide by our agreement except in emergencies. Please contact our Privacy Officer if you want to further restrict access to your health care information. This request must be submitted in writing. We will not sell your information for fundraising or marketing purposes without your permission.

Breach Notifications: You will be notified if your information is subject to breach. If we were to contact you to raise funds, you have the right to opt out of receiving such communications.

QUESTIONS AND COMPLAINTS

You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us. In writing, request a Complaint Form from our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

HOW TO CONTACT US

Administrator
Wilshire Surgery Center
9775 SW Wilshire Street, Suite 250
Portland, Oregon 97225
Phone (503) 688-5180
Fax (503) 688-5199

 

By signing below, you are acknowledging that you have read and understand our HIPAA Privacy Notice. A copy will be sent to your email address upon completion of the registration process.

All patients are notified in advance of their procedure, that it is the policy of Wilshire Surgery Center, regardless of the contents of any Advance Directive or instructions from a health care surrogate or attorney-in-fact, that if an adverse event occurs during the course of treatment, resuscitative or other stabilizing measures will be initiated and he/she will be transferred to an acute care hospital for further evaluation. At the receiving facility, further treatments or withdrawal of treatment measures already begun will be ordered in accordance with the patient’s wishes, Advance Directive, or health care Power of Attorney.

 

By signing below, you are acknowledging that you have read and understand the our policies regarding an Advance Directive/Living Will. A copy will be sent to your email address upon completion of the registration process.

PATIENT RIGHTS
• You have the right to personal privacy and care in a safe setting free of all forms of abuse, harassment, discrimination or reprisal.
• You have the right to accurate and easily understood information about your health plan, treatment, health care professionals, and health care facilities. If you speak another language, have a physical or mental disability, or just do not understand something, help should be given so you can make informed health care decisions prior to your treatment or procedure.
• You have the right to choose health care providers who can give you high-quality health care.
• If you have severe pain, an injury, or sudden illness that makes you believe that your health is in serious danger, you have the right to be screened and stabilized using emergency services. You should be able to use these services whenever and wherever you need them, without needing to wait for authorization and without any financial penalty.
• You have the right to know your treatment options and take part in decisions about your care. Parents, guardians, family members, or surrogates that you select can represent you if you cannot make your own decisions according to state law. If a patient is adjudged incompetent under applicable state health and safety laws by a court of proper jurisdiction, the rights of the patient are to be exercised by the person appointed under state law to act on your behalf.
• You have a right to considerate, respectful care from your doctors, health plan representatives and other health care providers that does not discriminate against you.
• You have the right to talk privately with health care providers and to have your health care information protected. You also have the right to read and copy your own medical record. You have the right to ask that your doctor change your record if it is not correct, relevant or complete. Unless authorized by law, you have the right to approve or refuse record release.
• You have the right to a fair, fast, and objective review of any complaint you have against your health plan, doctors, hospitals or other health care personnel without fear of reprisal. This includes complaints about waiting times, operating hours, the actions of health care personnel, and the adequacy (or lack of) of treatment or care.
• You have the right to submit a grievance either verbally or in writing to: Administrator of Wilshire Surgery Center, 9775 SW Wilshire St Ste 250, Portland Oregon 97225, 503-688-5185. You will receive a written notice of decision within 14 business days describing the steps taken to investigate, the results, and the completion date.
• Contact information if you feel as if any Rights were violated are as follows: Office of Medicare Beneficiary Ombudsman Website: https://www.medicare.gov/claims-appeals/your-medicare-rights/get-help-with-your-rights-protections, or contact Medicare at 1-800-MEDICARE, or the Oregon Health Authority, Health Care Regulation and Quality Improvement, 800 NE Oregon St Ste 465, Portland Oregon 97232-2162, www.oregon.gov/DHS/admin, 1-971-673-0540.

PATIENT RESPONSIBILITIES
• You have the responsibility to provide to the best of your knowledge, accurate and complete health information.
• You are responsible to participate in your plan of care & provide an Advance Directive if you have one.
• You are responsible for following the treatment plan recommended.
• You are responsible for making known whether or not you clearly understand the medical treatment plan.
• You must have a responsible adult to provide you transportation and assist with your care for the first 24 hours after your surgery.

 

By signing below, you are acknowledging that you have read and understand the Patient Rights and Responsibilities notice. A copy will be sent to your email address upon completion of the registration process.

By signing below, you are acknowledging that you have read and consent to the release and transfer of your medical records, in the unlikely event that it becomes medically necessary for transport to a nearby hospital while in the Wilshire Surgery Center. You are further consenting to the release of related hospital records to Wilshire Surgery Center upon discharge from the hospital.