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Please bring the following with you to Tri City Surgery Center: - page 8 / 15

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TRI CITY SURGERY CENTER

NOTICE TO PATIENTS: Physician Financial Ownership

We are required by Federal law to notify you that physicians hold financial interests or ownership in this ASC. We are required by 42 C.F.R. § 416.50 to disclose this financial interest or ownership in writing and in advance of the date of the procedure you are scheduled to receive at the facility. A list of physicians who have a financial interest in this ASC is listed below:

  • 1.

    Mark Fetter, M.D.

  • 2.

    Stephen Knecht, MD

  • 3.

    Mark Mellinger, MD

  • 4.

    Eric Nelson, M.D.

  • 5.

    Kent Peterson, DPM

  • 6.

    Richard Pleva, M.D.

  • 7.

    Scott Price, M.D.

  • 8.

    Brian Schilperoort, M.D.

  • 9.

    Angela Wang, M.D.

Please be advised that you may choose any other organization for the purpose of obtaining the services ordered or requested.

NOTICE TO PATIENTS: Policy for Advanced Directives

Advance directive is a general term that refers to your oral or written instructions about your future medical care in the event that you become unable to communicate those instructions. As a provider of outpatient services, it is the policy of Tri City Surgery Center that Advance Directives will NOT be honored. Tri City Surgery Center will provide full resuscitative service for any patient requiring emergency life saving/support. Cancellation of your procedure due to the facility’s policy regarding Advance Directives must be discussed with your physician prior to the date of service.

If you would like information on developing Advanced Directives, the following website can assist you and includes a description of the State’s health and safety laws:

http://www.uslivingwillregistry.com/forms/shtm

Additionally, upon request, we will provide you with official State advance directive forms.

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