Before You Arrive

VIEW AND DOWNLOAD OUR FINANCIAL POLICY FORM Please download the Financial Policy, review, print and sign prior to arriving. Please provide the signed document to the front desk upon arrival.

Patients may access the State of Florida’s Agency for Healthcare Administration website at this link for information about this surgery center:

Information on payments made to the facility for defined bundles of services and procedures is available at . The service bundle information is a non-personalized estimate of costs that may be incurred by the patient for anticipated services, actual costs will be based on services provided to the patient at the time of service.

Upon a patient’s request, SCCF and health care providers can provide a more personalized estimate of charges and other information prior to the service, including patients with no insurance. Please note that the payments and payment ranges are an estimate of the cost that may be incurred and your actual cost may vary based on actual services rendered. You may pay less for this procedure or service at another facility or in another health care setting. Services may be provided in this health care facility by the facility as well as by other health care providers who may separately bill the patient and who may or may not participate with the same health insurers or health maintenance organizations as the facility.
Patients and prospective patients may request from this facility and other health care providers a more personalized estimate of charges and other information. Patients and prospective patients should contact each health care practitioner who will provide services in the ASC to determine the health insurers and health maintenance organizations with which the health care practitioner participates as a network provider or preferred provider. Please see the providers tab on our website for more information on the providers that render services at SCCF.

Charity care is not offered to patients at this time. If you do not have insurance, you are responsible for the payment of all services and fees. Please see our financial assistance programs available.

Our financial assistance program offers a variety of ways to reduce a patient’s financial responsibility for services rendered by the facility. Our program structures a balance between offering the patient a reduced financial liability while still complying with insurance contract obligations and Federal and state regulations.

Payment Plans: Each patient is expected to pay his/her estimated financial liability on or before the day of service. In the event a patient is unable to pay the estimated liability in full, our facility may offer a short term repayment schedule after a minimum down payment is made and a secured credit card is on file for scheduled monthly payments. For an extended repayment schedule, a patient may need to secure financing with an outside source. Please consult with our business office for further information.

Uninsured (self-pay) Discounts: Patients who are not eligible to receive services paid for by insurance or other third party payment sources may be eligible to receive an uninsured discount from our facility. The discount is a set percentage off of our usual & customary fee schedule charges and is subject to change. If a patient’s services are subsequently found to be covered by insurance or other third party payment source, the uninsured discount may be disallowed.

In consideration of medical treatment and services provided to the above named patient, the undersigned unconditionally guarantees payment of the account charges and balance in full to SCCF at discharge of the patient. SCCF will process verified and assigned insurance claims as a courtesy to the patient.

All uninsured balances or amounts remain payable at discharge. A late payment charge of 1.5% per month (18% per annum) will be charged on any unpaid balance not paid within 90 days of the procedure you receive at SCCF. SCCF’s efforts to collect insurance proceeds do not affect the patient/undersigned’s responsibility for any account balance. If SCCF finds it necessary to refer this account for collection to enforce the obligation of the patient and/or the undersigned party/parties, the patient and/or undersigned agrees to pay any and all additional collection expenses, including SCCF’s reasonable Attorney’s fee. The proper venue for any legal action shall be in Polk County, Florida.