Patient Information

OUR CONCERN FOR YOUR SAFETY

The Surgical Center at Cedar Knolls, LLC, continues to strive to make healthcare safety a priority. You, as the patient, can also play a role in making your care safe by becoming an active, involved, and informed member of your healthcare team.

While you are a patient at our facility, we want you to feel comfortable to do the following:

• Expect our nursing staff to introduce themselves when they enter your room and look for their nametags.
• Ask about the purpose of medications you are given, including possible side effects. Make sure you can read the handwriting on any prescriptions written by your doctor. Don't be afraid to tell the nurse or doctor if you think you are about to receive the wrong medication.
• Do not hesitate to tell a member of our staff if you think he or she has confused you with another patient.
• Expect our clinical staff to have washed their hands.
• Make sure your nurse or doctor confirms your identity, that is, checks your wristband and asks your name and birth date, before he or she administers any medication or treatment.
• Educate yourself about your diagnosis and planned surgical procedure.
• Thoroughly read all forms and consent for surgery and make sure you understand them before signing. If you don't understand, ask our staff or your doctor to explain them.
• Expect your doctor, with your participation, to mark the area that is to be operated upon.
• Prior to leaving our facility, be sure that you understand all of the postoperative instructions.
• Consider asking your companion to ask questions that you may not think of, to help you remember answers to questions you have asked, and to speak up for you if you cannot.
• Make sure your companion understands the type of care you will need when you get home. Your companion should know what to look for if your condition gets worse and whom to call if help is needed.
• Please speak up if you have questions or concerns, and if it is still unclear, ask again. Don't hesitate to ask about your safety. Tell your nurse or doctor if something doesn't seem quite right.
• Participate in all decisions about your treatment.

PLEASE ASK TO SPEAK TO A MANAGER IF YOU HAVE ANY CONCERNS ABOUT YOUR SAFETY.

I. The patient shall be informed of his/her rights as evidenced by written documentation of a signed copy of the patient's statement of rights and a verbal explanation given, in terms that the patient can understand. The signed copy of the Statement on Patient Rights will be placed in the patient's chart as part of the permanent medical record.

II. The patient will be informed of the services offered at the Surgery Center, the names of the professional staff and their professional status of who is providing and/or responsible for their care.

III. The patient will be informed of the fees and related charges, including the payment, fee, deposit, and refund policy of the Surgery Center and any charges not covered by third-party payers or by the Surgery Center's basic rate.

IV. The patient will be informed of other healthcare and educational institutions participating in the patient's treatment.

V. The patient will be informed of the identity and the function of these institutions, and he/she has the right to refuse the use of such institutions.

VI. The patient will be informed, in terms that the patient can understand, of his/her complete medical/health condition or diagnosis, the recommended treatment, treatment options, including the option of no treatment, risks of treatment, and expected results. If this information would be detrimental to the patient's health, or if the patient is not capable of understanding the information, then the information will be provided to the patient's next of kin or guardian. This release of information to the next of kin or guardian, along with the reason for not informing the patient directly, will be documented in the patient's chart.

VII. The patient will participate in the planning of his/her care and has the right to refuse such care and medication. Upon refusal, it will be documented in the patient's chart.

VIII. The patient will be included in experimental care if the patient has agreed to such and gives written and informed consent to such treatment, or when a guardian has consented to such treatment. The patient also has the right to refuse such experimental treatment.

IX. The patient has the right to voice grievances or recommend changes in policies and services to the Surgery Center personnel, the governing authority and/or outside representatives of the patient's choice, free from restraint, interference, coercion, discrimination, or reprisal.

X. The patient will be free from mental and physical abuse, free from exploitation, and free from use of restraints unless they are authorized by a physician for a limited period of time to protect the patient or others from injury. Drugs and other medications shall not be used for discipline of patients or for convenience of the Surgery Center's personnel.

XI. The patient will be assured of confidential treatment of information about him/herself. Information in the patient's medical record shall not be released to anyone outside the facility without the patient's approval, unless another healthcare facility to which the patient was transferred requires that information, or unless the release of the information is required or permitted by law, a third-party payment contract, or a peer review, or unless the information is needed by the New Jersey State Department of Health for statutory authorized purposes. The facility may release data about the patient for studies containing aggregated statistics when the patient's identity is masked.

XII. The patient will receive courteous treatment, consideration, respect and recognition of the patient's dignity, individuality, and right to privacy, including, but not limited to, auditory and visual privacy. The patient's privacy shall also be respected when facility personnel are discussing the patient.

XIII. The patient will not be required to work for the facility unless the work is part of the patient's treatment and is performed voluntarily by the patient. Such work shall be in accordance with local, State, and Federal laws and rules.

XIV. The patient has the right to exercise civil and religious liberties, including the right to independent personal decisions. No religious beliefs or practices, or any attendance at religious services, shall be imposed upon any patient.

XV. The patient will not be discriminated against because of age, race, religion, sex, nationality, or ability to pay, or deprived of any constitutional, civil, and/or legal rights solely because of receiving services from the facility.

XVI. The Administrator will provide upon request to all patients and/or their families, the names, addresses, and telephone numbers of the following offices where complaints may be lodged:

Division of Health Facilities Evaluation and Licensing
New Jersey Department of Health
PO Box 367, Trenton, NJ 08625-0367  •  (609) 792-9770   or   PO Box 808, Trenton, NJ 08625-808  •  (609) 624-4262
Or: the Website for the Office of the Medicare Beneficiary Ombudsman

XVII. The Administrator shall also provide all patients and/or their families, upon request, the names, addresses and telephone numbers of offices where information concerning Medicare and Medicaid coverage may be obtained.

XVIII. Addresses and telephone numbers contained in XVI will be conspicuously posted throughout the facility, including, but not limited to, the admissions waiting room, the patient service area of the business office, and other public areas.

XIX. To expect and receive appropriate assessment, management, and treatment of pain as an integral component of that person's care in accordance with N.J.A.C.8:43E-6

XX. If a patient is adjudged incompetent under applicable State laws by a court of proper jurisdiction, the rights of the patient are exercised by the person appointed under State law to act on the patient's behalf.

XXI. If a State court has not adjudged a patent incompetent, ay legal representative designated by the patient in accordance with State law may exercise the patient's rights to the extent allowed by State law.

Patient Responsibilities: The patient has the responsibility to do the following:

I. The patient is encouraged to ask any and all questions to the physician and staff in order that he/she may have a full knowledge of the procedure and aftercare.

II. Follow the treatment plan prescribed by his/her provider and participate in his/her care.

III. Provide complete and accurate information to the best of his/her ability about his/her health, any medications, including over-the-counter products and dietary supplements and any allergies or sensitivities.

IV. Provide the organization with information about their expectations of and satisfaction with the organization.

V. Provide a responsible adult to transport him/her home from the facility and remain with him/her for 24 hours, if required by his/her provider.

VI. Inform his/her provider about a living will, medical power of attorney, or other directive that could affect his/her care.

VII. Make known your wishes in regard to anatomical gifts. You may document your wishes in your healthcare proxy.

VIII. Supply insurance information and pay bills promptly so that the Surgical Center at Cedar Knolls can continue to serve you effectively.

IX. Accept personal financial responsibility for any charges not covered by his/her insurance.

X. Be respectful of all the healthcare providers and staff, as well as the other patients.

Public law/rule of the State of New Jersey/Board of Medical Examiners mandates that a physician, podiatrist, and all other licensees of the Board of Medical Examiners inform patients of any significant financial interest held in a healthcare service. Accordingly, please take notice that practitioners in this office do have a financial interest in the following healthcare service(s) to which patients are referred:

Surgical Center at Cedar Knolls, LLC

You may, of course, seek treatment at a healthcare service provider of your own choice. A listing of alternative healthcare service providers can be found in the classified section of your telephone directory under the appropriate heading.

Additionally, please be advised that the procedure(s) you are scheduled to undergo at Surgical Center at Cedar Knolls, LLC may be considered to be "out-of-network” services and reimbursed at an "out-of-network" level by your insurance carrier.

The Centers for Medicare & Medicaid Services Conditions of Coverage regarding ambulatory surgical centers mandate that ambulatory surgical centers disclose to patients a physician's financial interest in an ambulatory surgical center to which the physician refers his or her patients. Accordingly, please take notice of the following information:

The following physicians are ownership partners in Surgical Center at Cedar Knolls LLC, a surgical center to which they refer patients:

Physician Owners of Surgical Center at Cedar Knolls, LLC

• R. Boiardo, M.D.
• R. D'Agostini, M.D.
• D. Epstein, M.D.
• R. Fox, M.D.
• R. Goldman, M.D.
• S. Hunt, M.D.
• A. Kirschenbaum, M.D.
• M. McBride, M.D.
• K. Montgomery, M.D.
• A. Willis, M.D.
• J. Shearin, M.D.
• L. Shrem, M.D.
• R. Thiele, D.P.M.

PATIENT INFORMATION ON ADVANCE DIRECTIVES

In advance of the date of your scheduled procedure at Surgical Center at Cedar Knolls, you will receive written information on state law, and Surgical Center at Cedar Knolls written policy, advising you of your right to make decisions concerning your medical care, including the right to accept or refuse medical or surgical treatment, and formulate advance directives (declaration and/or durable power of attorney for healthcare decisions), including:

• Proxy Directive
• Instruction Directive
• Combined Directive

You will not be discriminated against on your provision of care whether or not you have an Advance Directive. DNR orders will be suspended while you are a patient of the surgery center, but such information will be forwarded in the event you are transferred to the hospital.

You will be asked to assign all your benefits and rights from your insurance company to one or all of the medical providers designated below. You will be asked to assign all rights to pursue payment for service rendered to you by this medical procedure and the medical provider may proceed against said insurance company obligated to make payment to you or this medical provider for services rendered to you. In the event that the insurance company refuses to make such payment upon demand, you will be asked to expressly give permission for a cause of action to be brought in your name as assignee.

SURGICAL CENTER AT CEDAR KNOLLS
197 RIDGEDALE AVE., SUITE 100
CEDAR KNOLLS, NJ 07927

NORTHERN ANESTHESIA
PO BOX 95000-2555
PHILADELPHIA, PA 19195-2555

PHYSICIAN OFFICE PARTNERS
6050 SPRINT HIGHWAY, SUITE 300
OVERLAND PARK, KANSAS 66211

CONSENT TO THE ADMINISTRATION OF ANESTHESIA

You will be asked to consent to the administration of anesthetics and placement of monitoring devices deemed necessary, by and under the direction of Surgical Center at Cedar Knolls, in order to lessen the pain you would otherwise experience, and you will receive explanation in terms that you understand on one or more of the following forms of anesthetics that will be administered to you.

• Local (includes local anesthetics with or without intravenous sedatives)
• Conductive Anesthesia (includes epidural, spinal, and nerve blocks)
• General Anesthesia

During the course of a procedure, unforeseen changes in your condition may arise, which would necessitate changes in your care. In that case, the anesthesiologist will act on your behalf with safety as the first priority.

The practice of anesthesiology is not an exact science, and no guarantees can be made concerning the results of the anesthetics. Common side effects include: nausea and vomiting, headache, and backache. Other risks include, but are not limited to: awareness while under anesthesia, eye injury, damage to the mouth or teeth, pneumonia, damage to the liver or kidneys, adverse drug reaction, and in rare cases, permanent brain damage, heart attack, stroke, or death.

If you are pregnant, elective procedures should be postponed until after the baby is born. Although fetal complications of anesthesia are very rare, the risks to your baby include, but are not limited to: birth defects, premature labor, permanent brain damage, and death.

You will be asked to certify that you have told the anesthesiologist of:

1. All the major illnesses you have had
2. All past anesthetics along with any complications of these anesthetics known to you
3. Any drug allergies you have
4. All medications you have taken in the past 30 days

If you fail to recover from anesthesia sufficiently to return home, you will be admitted to the hospital, and you will need to preemptively consent to such admission.

You will be asked to certify that you have read and fully understand consent to anesthesia, which will be preceded by an explanation from Surgical Center at Cedar Knolls. Later, you will be asked to acknowledge and verify that you are satisfied that you have been adequately informed concerning material risks, complications, and possible alternatives, if any, including not having anesthesia, and specifically consent to such.

Our address and phone number is: 197 Ridgedale Ave., Cedar Knolls, NJ 07927  •  (973) 292-0700

• NPO - Nothing by mouth (including water, chewing gum, etc.) after 12 midnight.
• Leave money, jewelry, and valuables at home.
• Wear glasses if needed (no contacts).
• Wear loose, comfortable clothing (Knee Surgery—loose pants; Shoulder Surgery—button-down shirt; Hand Surgery—loose sleeves).
• Bring all insurance cards, identification cards, and any X-rays or MRI reports or films if requested by surgeon.
• Bring crutches, cane, or walker if prescribed by your surgeon.
• Asthma: If necessary, take 2 puffs of your inhaler before you come to the center. Bring any emergency inhalers with you.
• Diabetic: Withhold oral hypoglycemic drugs or insulin the morning of surgery. Bring these with you to the surgery center.
• Cardiac: Take heart medication, antihypertensive, and/or diuretic the morning of surgery with a small sip of water.
• Are you taking aspirin products? If so, check with MD when to discontinue.
• Do you take vitamins/herbal supplements? If so, check with MD when to discontinue.
• You must have a responsible adult to drive you home.
• Do you have an advance directive/living will? If yes, please bring a copy with you.

• Advance Directives
• Assignment of Benefits – AAA Anesthesia
• Assignment of Benefits – Center
• Assignment of Benefits – Northern Anesthesia
• Financial Disclosure
• Patient Responsibilities