FINANCIAL STATEMENT

The Center was established to meet the special needs of patients with gastrointestinal complaints or diseases. It is an “Ambulatory Surgery Center” specially designed for the practice of Gastroenterology -- no other medical procedures are performed here. The physicians providing services at our facility are Board-certified in Gastroenterology and Colorectal Surgeons and our clinical staff are trained professionals experienced in caring for our patients. The mission of the Center is to provide quality care in a specialized outpatient setting. Each patient will have our utmost careful and personalized attention.

By law, we are required to notify you that some of the physicians performing procedures here have a direct financial interest/ownership in this center.

In order to ensure that our patients understand their financial responsibility and our payment policies, we ask that you take a minute to read the following and discuss any questions you may have with our billing representative.

• The fee that we charge for our services is intended to cover the cost of operating this facility including equipment, staff, rent, supplies, etc. You will also receive a separate bill from the physician’s office for their professional services, as well as the anesthesiologist, certified nurse anesthetist, and possibly the laboratory for any pathology services. The facility, anesthesiologist, certified nurse anesthetist (CRNA), laboratory and physicians’ professional office are all separate legal entities providing separate and distinct services.

• As a courtesy to our patients, insurance claims will be submitted on the patient’s behalf to the insurance company specified during the registration process as long as we have the complete name and address of the insurance company, the subscriber’s name, social security number and birth date, and the group number and any other required pre-authorization for the procedure.

• All co-payments and deductibles will be billed by Physicians Endoscopy Billing Department as required by the contract between the patient, the insurer and our center.

• Some insurers require precertification, preauthorization or a written referral. It is the patient’

• We recognize that there may be times when full payment is not possible. Patients covered by insurers that our center has not contracted with or any patients without insurance are expected to pay a minimum of 50% of the procedure fee at the time of service and a minimum of one-third of the remaining balance over the three months following the date of service.