Patient Forms

Agreements and Policies

Patient Rights and Responsibilities

It is important to know your rights as a patient and also your responsibilities. The staff and personnel of Premier Eye Surgery Center recognize the basic human rights and responsibilities of our patients. Efforts are directed to providing care consistent with those basic human rights and responsibilities.

Your Rights as a Patient

To be treated with respect, consideration, and dignity.
To be treated in a safe environment, free from all forms of abuse and harassment
To expect quality care and service from Premier Eye Surgery Center and to know the services available at the facility.
To full consideration of privacy concerning your medical care.
To confidential treatment of your medical records and to know that you are given the opportunity to approve or refuse their release to outside parties except when otherwise required by law.
To be given the opportunity to participate in decisions involving your health care, except when such participation is contraindicated for medical reasons.
To receive from your Physician sufficient information to be able to understand the procedure or treatment being received in order to sign the operative consent.
To be informed of any persons other than routine personnel who will be observing or participating in your treatment.
To complete information concerning your diagnosis, treatment, and prognosis, in terms you can understand. If concern for your health makes it inadvisable to give such information to you, the information will be made available to an individual designated by you or to a legally authorized representative.
To be informed of the right to change Physicians, if other qualified Physicians are available
To refuse treatment and to be informed of the consequences of your actions.
To be given information concerning Advance Directives.
To know if any research will be done during treatment and to have the right to refuse.
To know, in advance, the estimated amount of your bill.
To examine and receive an explanation of the final bill, regardless of the source of payment.
To know the methods for expressing grievances and suggestions to Premier Eye Surgery Center.

Our Notice of Privacy Practices informs you on our Uses and Disclosures of: Treatment, Payment, Health Care Operations, Law Enforcement, Public Health reporting, Appointment Reminders, Information About Treatment, and Other uses.
Treatment
Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, a report of your operation will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment
Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Health Care Operations
Your health information may be used as necessary to support the day-to-day activities and management of Premier Eye Surgery Center. For example, information on the services you received may be used for budgeting, financial reporting and quality assurance activities.
more

Complaint & Grievance Procedure

We pride ourselves on creating a healing environment for our clients with exceptions care. However, if for any reason you have a complaint or a grievance about any of our services provided, we ask that you contact one of our patient representatives.

Premier Eye Surgery Center’s patient representatives are:
Jenelle Bartels, Nurse Administrator
Jennifer Battista, Business Manager
Notify either the Nursing Administrator or Business Manager if you feel that any rights have been violated, or if you have a complaint, or suggestion for improvement. This can be accomplished by completing and returning your patient questionnaire or by direct contact:
Premier Eye Surgery Center
1050 W. South Boulder Road
Suite 1100
Lafayette, Colorado 80026
303-801-3393

Complaints or concerns may be given verbally or in writing at any time to any staff member and will be submitted to one of the patient representatives by the next working day.
Complaints that cannot be resolved by the patient representatives shall be referred to the Medical Director no later than three (3) days after the receipt of the report of the patient representative to the patient.
more

Disclosure of Ownership

Premier Eye Surgery Center is a physician-owned entity in partnership with Boulder Community Health.

The following physicians have ownership: Dr. Donald Keller, Dr. Brian Nichols, Dr. Kevin Cuevas, Dr. Richard Stewart, Dr. Geeta Lalwani, Dr. Robert Courtney, and Dr. Mohammad Karbassi.

Your physician may have a financial interest in this surgery center.

Acknowledgement of Agreements and Policies

I have read and reviewed the following documentation and offered/received a copy of:

Rights & Responsibilities
Notice of Privacy Practice
Complaint & Grievance
Disclosure of Ownership

Acknowledgment of Advance Directive Policy

All patients have the right to participate in their own health care decisions and to make advance directives or to execute powers of attorney that authorize others to make decisions on their behalf based on the patient’s expressed wishes when the patient is unable to make decisions or unable to communicate decisions. Premier Eye Surgery Center respects and upholds those rights.

Because of the requirements of the Medical Treatment Act, we have developed a policy, that regardless of the contents of any Advance Directive or instructions from a health care surrogate or attorney in fact, if an adverse event occurs during your treatment at this facility, center staff will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation (“Policy”). At the acute care hospital further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive or Medical Durable Power of Attorney. Your signature below is your agreement to Premier Eye Surgery Center’s Policy and changes any Medical Durable Power of Attorney you may have to be the same as the Policy stated above for the current procedure or treatment to be performed on this visit to this surgery center.

Patient Financial Responisiblity Agreement

Patient Responsibility

Any fees collected at the time of service and any quotes regarding such fees are estimated based on the information available to us at the time of service. We rely on information provided by the responsible party regarding insurance coverage, information from the responsible party's insurance company, and procedure fees associated with the CPT codes scheduled/reserved and provided to us by your surgeon. This estimate does not include the fees for the physician or anesthesiologist. There may be additional charges should your surgeon perform a procedure that is different from, or in addition to what was scheduled for implants or other services which were not scheduled or quoted prior to surgery.

It is the patient's responsibility to understand their individual insurance benefits.

Payment Arrangements

Payment arrangements are available. Please ask about this option. Any payment arrangements must be made prior to services being provided.

Billing Practices

Premier Eye Surgery Center will bill the responsible party's insurance company for facility charges. Premier Eye Surgery Center will also collect any co-payments, coinsurance, and/or deductibles at the time of service. The responsible party will be billed for any remaining charges not covered by insurance, including co-payments, co-insurance and/or deductibles. Additionally, the responsible party will be billed for facility charges in full should the insurance company deny coverage due to lack of referral, no preauthorization, lack of proper reporting of incident/accident or lack of individual coverage, where applicable.

Your Rights and Protection Against Surprise Billing Act

Beginning January 1,2020, Colorado state law protects you from Surprise Billing,” also known as Balance Billing.” Also beginning January 1, 2022, Federal law protects you from “surprise billing” and “balance billing.”

YOUR RIGHTS ARE PROTECTIONS 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” OR “SURPRISE BILLING”?

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 must 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 can’t 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.

Patient Forms

Agreements and Policies

Admission Forms