Thank you for choosing MD Surgical Solutions Surgery Center for your outpatient
surgery center needs. Enclosed please find documents to review and sign prior to
your scheduled appointment. Reviewing these documents will help to expedite the
preoperative portion of your appointment.
-Assignment of Benefits
-Assignment of Benefits (page 2)
-Payment/No Show Policy
Please bring the enclosed documents with you on the day of your surgery. If you
have any questions regarding these documents or our policies please contact us at
818-906-2131 or we will be happy to answer them on the day of your surgery. We
look forward to working with you.
MD Surgical Solutions Management
Disclosure of Financial Interest
MD Surgical Solutions, LLC is owned and operated by Dr. Michael Lin, M.D and
Dr. Charles Blaine, DPM and associates.
Assignment of Benefits
I hereby assign all medical and surgical benefits, to include major medical benefits
to which I am entitled. I hereby authorize and direct my insurance carrier(s),
including Medicare, private insurance, and any other health/medical plan, to issue
payment check(s) directly to MD Surgical Solutions, LLC for services rendered to
myself regardless of my insurance benefits, if any. Additionally, I request that
payment of authorized Medi-gap benefits be made to either me or on my behalf to
MD Surgical Solutions for any services furnished. I authorize any benefits or the
benefits payable for related services.
I understand that I am responsible for any amount not covered by my insurance.
Authorization to Release Information
I hereby authorize MD Surgical Solutions, LLC to 1) release any information
necessary to insurance carriers regarding my illness and treatments 2) process
insurance claims generated in the course of examination or treatment, and 3) allow
a photocopy of my signature to be used to process insurance claims for the period
of lifetime. This order will remain in effect until revoked by me in writing.
I have requested medical services from MD Surgical Solutions, LLC on behalf of
myself, and understand that by making this request, I become fully financially
responsible for any and all charges incurred in the course of the treatment
I further understand that fees are due payable on the date that services are
rendered and agree to pay all such charges incurred in full immediately upon
presentation of the appropriate statement. A photocopy of this assignment is to be
considered as valid as the original.
Patient/ Responsible Party Signature Date
ASSIGNMENT OF BENEFITS
REQUEST FOR CHECK TO BE SENT DIRECTLY TO MY PROVIDER
I understand that if the provider rendering services to me, be it either the physician
and /or the facility, is not contracted with my insurance company, that it is possible the
check for their services may be sent to me, I respectfully request, however, for the
provider(s) listed below, the check(s) be sent directly to the providers (s). I do not want
the check, under any circumstances, to be sent to me, I will, therefore, expect that any
and all payments will be sent directly to my provider unless I hear differently from one
of your representatives.
Please send all my checks to:
MD Surgical Solutions, LLC
15477 Ventura Blvd. Suite 103
Sherman Oaks, CA 91403
Provider and/or Facility
I acknowledge the possibility that a check, and /or checks may be sent directly to
me instead of to you, my provider. I understand this money is not mine even though
the check may be written to me. I understand you are billing my insurance company as
a courtesy to me but the money paid by the insurance company belongs entirely to you.
I, therefore, agree to immediately, but certainly no later than 48 hours upon receipt of
any such money, forward this money directly to you. I will make no attempt to
negotiate what portion I sent to you. In any event, I acknowledge and agree that any
changes for services rendered to me are my responsibility and I will pay all fees
including any co-pays or deductibles, if applicable.
NOTE: Please read the above agreements carefully and make sure that you
understand all terms and conditions before signing below. If you do not understand
please review contents with staff prior to signing.
Agreed to and accepted by:
Patient Signature Patient Printed Name Date
Witness Signature Witness Printed Name Date
ASSIGNMENT OF BENEFITS
Acknowledgement of Receipt of Privacy Notice
I, _____________________________ have been presented with a copy of this provider’s Notice of
Privacy Policies, detailing how my information may be used and disclosed as permitted under federal
and state law. I have received a copy of the patients Bill of Rights, and the Patient responsibility form. I
have received information about the policy on Advance Directives. I have been informed that my
Medical Records may be subject to outside Peer Review. I have received a copy of MD Solutions
Surgery Center’s Grievance Procedures. I understand that MD Surgical Solutions Surgery Center has
been surveyed and operates under the standards of AAAHC. I understand the contents of the Notice,
and I request the following restriction(s) concerning my personal medical information:
3201 Old Glenview Road, Suite 300
Wilmette, IL. 60091-2992
Further, I permit a copy of this authorization to be used in place of the original, and request payment of
medical insurance benefits either to myself or to the party who accepts assignment. Regulations
pertaining to medical assignment of benefits apply.
Signed: ____________________ Date: ___________________
Patient Payment Policy
Thank you for choosing our Surgery Center. We are committed to providing you the best possible
medical care. The following information is provided to avoid any confusion regarding payment for
surgery facility services. Our billing service will work with you to see that your claim is filed
accurately and promptly.
Please sign below to acknowledge that you have read and agree to this policy.
For procedures performed in the surgery center, there may be up to three separate
and independent bills
1. Facility charge: Surgical Center and supplies ___________(Please Initial)
2. Surgeon professional fees ___________(Please Initial)
3. Anesthesia fees ___________(Please Initial)
If we are in-network with your insurance plan, we will not discount our services by any
further amount after your insurance company has processed your claim and informed us of
We require a $500.00 deposit for procedures that require anesthesia other than local
If we are not a contracted provider for your insurance company, we will bill them as a
courtesy on your behalf.
It is our preference to establish a credit card payment plan that we will use for
settlement of all your account balances. Checks will only be accepted from established
patients. For further details please call our accounting department.
If your account is overdue for more than 120 days after your insurance has paid, it will be
referred to a collection agency. This is done reluctantly as a last resort, after we have
exhausted all efforts for voluntary payment.
New patients, and those who have no insurance, are required to pay at the time of service
with either a credit card or cash. We do not accept personal checks.
No Show Policy:
Please notify our office 24 hours in advance if you are unable to keep your scheduled
appointment. If you do not notify us and miss your appointment completely, we require that you
pay a $75.00 missed appointment fee before we will book you another office appointment.
Anesthesia other than Local:
Please notify our office 48 hours in advance if you are unable to keep your scheduled
appointment. We require a $500.00 deposit for these procedures. If you do not notify us and miss
your appointment completely, you will forfeit your deposit.
Acknowledgement and Authorization
I have read, understand and agree to abide by the above policies. I understand that charges not
covered by my insurance company, as well as co-payments and deductibles are my responsibility.
I authorize my insurance benefits to be paid directly to: MD SURGICAL SOLUTIONS
PAYMENT/ NO SHOW POLICY
MEDICAL HARDSHIP LETTER
MD Surgical Solutions LLC
15477 Ventura Blvd. Suite 103
Sherman Oaks CA 91403
Dear MD Surgical Solutions,
This is the medical hardship letter to state my inability to pay the bill for the procedure
performed on ______________.
Please understand that this is neither a refusal to pay nor a dispute of the charges, but
simply an explanation of my financial situation.
My current income is just enough to cover basic necessities and by paying your charges as
required, would lead to a serious financial hardship for my family and myself. With that
said, I would like to propose waiving the amount I owe you.
I am truly hoping for your favorable response.
Thank you for your understanding.
Informed Consent For Surgery
Patient __________________________________ Date __________________ Time_______________
I am scheduled for outpatient surgery on ____/____/ 20 12
I am scheduled to have:
Skin Excision and Repair (including complex repair, flap or graft if necessary)
Mohs Surgery and Skin Repair (including complex repair, flap or graft if necessary)
Mohs Skin Repair (including complex repair, flap or graft if necessary)
Incision and Drainage of abscess
The surgery is to be performed by Dr. ____________________________________and such assistants as may be selected
by him. I have been informed, and I understand to my satisfaction, the above-mentioned procedure(s), why it is necessary,
the risks to my health if the condition remains untreated and what the procedure will entail.
I herein give my permission for the procedure above and administration of pre-surgery medication and anesthesia for
The advantages and disadvantages of outpatient surgery have been explained to me as well as the procedure, which will be
performed, on me. I understand that during the course of the operation, unforeseen conditions may be revealed that
necessitates an extension of the original procedure(s) or different procedure(s) than those planned. I authorize the above
named surgeon or his designee(s) to perform such surgical procedures as are necessary and desirable in the exercise of
professional judgment. _________ (Please Initial)
I have been made aware that there are certain risks inherent to the performing of any surgical procedure such as: loss of
blood, infection, hematoma, pain, tingling, numbness or other nerve sensations including nerve damage, reactions to
anesthesia and the formation of thick or otherwise objectionable scars. Additionally, I acknowledge that the doctor has made
no promises to me, oral or written, in connection with the operation. I recognize that every surgical procedure involves
uncertainty and that no result can ever be guaranteed.
_________ (Please Initial)
I release the doctor from any responsibility, which takes place as a natural complication of the procedure. I also realize it is
my responsibility to keep postoperative appointments. If I feel any problems exist such as bleeding, infection or if I have any
doubts, I am to contact the doctor as soon as possible.
For the purpose of advancing medical education, I consent to photographing and/or recording of the operation provided my
identity is not revealed by the pictures or descriptive text accompanying them. The photographs and information relating to
my case may be published or used for any other professional purpose.
I consent to the disposal of any tissue, which is removed in accordance with accustomed practice and procedure. I give My
permission to have any tissue removed during the procedure sent for histological examination to a pathologist.
I understand that MD Surgical Solutions, LLC does not honor advance directives. _________(Please Initial)
I have received a copy of my Rights and Responsibilities as a patient _____________(Please Initial)
Patient / Guardian Signature: Relationship Date
Witness Signature Date
Physician Signature Date
PATIENT SELF ASSESSMENT
Please fill out and hand to the receptionist when completed.
Allergies to Medication (if Any): Sensitivities: Yes No
HEIGHT: ________________________ WEIGHT: ______________________ AGE: _________
List medications that you are currently taking (include aspirin, natural herb supplements and diet pills)
See attached list
1) ___________________________________ Dose_________________________ how often? _________________
2) ___________________________________ Dose_________________________ how often? _________________
3) ___________________________________ Dose_________________________ how often? _________________
4) ___________________________________ Dose_________________________ how often? _________________
5) ___________________________________ Dose_________________________ how often? _________________
List previous surgeries or procedures and year performed:
PAST OR PRESENT HEALTH HISTORY (Circle Yes or No)
Health Issue Explain Health Issue Explain
High Blood Pressure Yes No Arthritis Yes No
Stroke Yes No Headaches Yes No
Smoking Yes No Thyroid Disorder Yes No
Lung Disease Yes No Anesthesia Problems Yes No
Diabetes Yes No Prosthesis/Implants/Pacemaker Yes No
Heart Disease Yes No Bleeding Disorders Yes No
Liver Disease Yes No Seizure Disorder Yes No
Kidney Disease Yes No Eye Disorder Yes No
Cancer Yes No Recent Cold/flu/infection Yes No
Gastric Reflux Yes No Pregnant Yes No N/A
Patient signature Date
If signed by other than patient, indicate relationship
Patient Name: __________________
PATIENT SELF ASSESSMENT DOS: _________________________
DISCHARGE/POSTOP WOUND CARE INSTRUCTIONS
FOR THE NEXT 24 HOURS: No alcohol, aspirin, or making any important decisions
ACTIVITY: Avoid strenuous physical activities. Do not lift weights over 10 lbs for the next
few weeks. Remember, at time of suture removal, skin is only about 10% of normal
1) Keep the dressing clean and dry until removed.
2) You may remove the dressing in 24-48 hours.
3) Clean wound gently with half strength hydrogen peroxide or mild soap twice daily.
** No scabbing or crusting should be allowed to develop**
4) Apply thin layer of double antibiotic (Polysporin®) or petrolatum jelly
(Vaseline®) after each cleansing. (moist wounds heal faster). Triple
antibiotic (Neosporin®) is ok if you have used it before, but some people
5) Apply a new Band-Aid or dressing after applying ointment. Keep wound site elevated.
6) Ice packs (or frozen peas) may be applied for pain or swelling for the first 48-72 hours.
IF BLEEDING OCCURS:
Slight bleeding is normal. If brisk bleeding occurs, apply direct uninterrupted pressure for 15-
20 minutes. (use watch or clock to time). If bleeding does not stop, contact our office or go the
nearest emergency room.
Please avoid aspirin or medications containing aspirin ie: ibuprofen or Advil
for 3-4 days following surgery. You may use extra strength Tylenol for pain (2 tablets every 6
hours). Take the oral antibiotics as prescribed by the doctor.
Please call the office promptly if you develop any of the following symptoms:
1) Prominent redness, swelling, or white discharge at the surgical site.
2) Fever over 101 F.
3) Bleeding as noted above or extensive bruising. (Some bruising is expected)
In Case of Emergency, please call the office immediately at (888) 558-
8955 and ask to speak to one of the providers. If it is after hours, the
paging service will be contacted. If you need immediate medical attention,
please call 9-1-1 or go to the nearest emergency room.
Patient signature _____________________________Date_____________
Nurse/Tech signature_________________________ Date_____________
Patient Name: __________________
DISCHARGE INSTRUCTIONS DOS: _________________________
Postoperative Phone Call
Patient Name: _____________________________ Phone: _______________________________
Procedure: _______________________________Date of Surgery: ________________________
Name of operating physician: _____________________________________
□ 1 □ 2 □ 3 □ seen in office
Date: Date: Date:
Time: Time: Time:
Patient Contacted on: ________________ at ____________ a.m. / p.m.
Post Surgical Condition:
1. Redness/Swelling of operative site □ □
2. Bleeding from operative site □ □
3. Drainage from operative site □ □
4. Pain in operative site □ □
Other: YES NO
a. Headache □ □
b. Nausea □ □
c. Vomiting □ □
d. Cough □ □
Comments on any YES response or on additional advice given:
Signature and title of phone interviewer Date
Patient Name: __________________
FOLLOW UP PHONE CALL DOS: _________________________