Patients treated at the Center have the right to:
• Be treated with respect, consideration, and dignity.
• Be provided with appropriate personal privacy at check-in and in evaluation and treatment areas of the Center.
• Have interpretation services available at no extra charge to the patient.
• Be provided with information, in layman’s terms, concerning their diagnosis, evaluation, treatment, and prognosis to the degree that it is known. When it is medically inadvisable to give such information to a patient, the information is provided to a person designated by the patient or to a legally authorized person.
• Be given the opportunity to participate in decisions involving their healthcare, except when such participation is contraindicated for medical reasons.
• Receive service(s) without regard to age; race; color; sex; sexual orientation; marital status; disability; veteran’s status; national origin; cultural, economic, educational, or religious background; or the source of payment for care, without being subjected to discrimination, reprisal, abuse, or harassment.
• Receive care in a safe setting by competent and appropriately qualified personnel.
• Be given verbal and written notice of rights and responsibilities in a language and manner that ensures the patient, the representative or surrogate understands, prior to the procedure.
• Have these patient rights posted in a place or places within the ASC likely to be noticed by patients waiting
for treatment or by the patient’s representative or surrogate, if applicable.
• Be provided, in writing if requested, a list of physicians who have financial interest or ownership in the
ASC facility.
• Be informed of how to voice or file complaints or grievances regarding treatment or care that is (or fails to be) furnished.
• Change primary or specialty physicians if other qualified physicians are available.
• Be given the name of their attending physician, the names of all other physicians directly assisting in their care, and the names and functions of other health care persons having direct contact with the patient.
• Be informed of the after-hour and emergency care coverage.
• Be informed of the services, fees, and payment policies of the center.
• Be provided information on the credentials of the healthcare professionals at the Center.
• Receive information regarding the absence of malpractice insurance, if applicable.
• Be fully informed about a treatment, procedure, anesthetic administration, and the expected outcome before it is performed.
• Refuse drugs or procedures and have a physician explain the medical consequences of the drugs or procedures.
• Have a legal representative or surrogate designated by the patient in accordance with state law to exercise the patient’s rights to the extent allowed by state law, if a state court has not adjudged a patient incompetent.
• Have the rights of the patient exercised by the person appointed under state law to act on the patient’s
behalf if a patient is adjudged incompetent under applicable state laws by a court of proper jurisdiction.
• Expect emergency procedures to be implemented without necessary delay.
• The expedient and professional transfer to another facility when medically necessary and to have the
responsible person and the facility that the patient is transferred to notified prior to transfer.
• Have records pertaining to their medical care treated as confidential.
• Be provided with, upon written request, access to all information contained in their medical record.
• Be advised of participation in a medical care research program or donor program; the patient shall give
consent prior to participation in such a program; a patient may also refuse to continue in a program that
has previously given informed consent to participate in.
• Receive appropriate and timely follow-up information of abnormal findings and tests.
• Receive appropriate and timely referrals and consultation, and information regarding “continuity of care.”
• Expect the absence of clinically unnecessary diagnostic or therapeutic procedures.
• Submit an advance directive and obtain written information concerning the Center’s policies on
advance directives, including a description of applicable state health and safety laws and State advance directive forms if requested.
Advance Directives:
All patients have the right to make advance directives or to execute powers of attorney that authorize others
to make decisions on the patient’s behalf based on their expressed wishes when unable to make or
communicate decisions. This Center respects and uphold those rights.
Documentation in a prominent part of the patient’s current medical record indicates whether or not the
individual has executed an advance directive.
However, unlike an acute care hospital setting, most procedures performed in this facility are minimal risk. Of
course, no surgery is without risk, and you will discuss procedure specifics (risks, recovery, after-care) with your physician. Therefore, it is our policy, regardless of the contents of any advance directive or instructions from a healthcare surrogate, attorney-in-fact, or holder of a healthcare provider, that if an adverse event occurs during your treatment at the Center we will initiate resuscitative or other stabilizing measures and transfer you to an acute care hospital for further evaluation. 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 healthcare power of attorney.
For further clarification, please request to speak with the Center’s Clinical Director at (913) 382-4444.
You have the right to access the Advance Health Care Directive described in Caring Connections, a national
program of the National Hospice and Palliative Care Organization (NHPCO).
This program, aimed at improving care at the end of life, includes:
• Instructions for completing the Kansas Advance Directive for Healthcare
• Learning options for end-of-life services and care
• How to make sure that your wishes are honored
• How to tell your family, friends, and healthcare providers about your decision
• How to participate in personal and community efforts to improve end-of-life care
• A copy of the Kansas Durable Power of Attorney for Healthcare
This information is available on the National Hospice and Palliative Care Organization’s website at: https://
www.nhpco.org/wp-content/uploads/Kansas.pdf
Upon request, you, your representative, or your surrogate, can obtain a copy of your state’s Advance Directive form at the Center.
Each patient treated at the Center has the responsibility to:
• Provide a complete and accurate medical history including medications, over-the counter products,
dietary supplements, and any allergies or sensitivities.
• Follow the treatment plan established by the physician, including instructions of nurses and
other healthcare professionals as they carry out the physician’s orders.
• Arrange for a responsible adult to drive you home and stay with you for 24 hours after surgery (as may be
required by your physician).
• Fulfill financial responsibility, for all services received, as determined by the patient’s insurance carrier.
• Provide the surgery center with all information regarding third-party insurance coverage.
• Behave respectfully toward all healthcare professionals, as well as other patients.
• Keep your appointment and notify the facility if you are unable to do so.
• Read and understand all consents you sign. Please ask questions for clarification before signing consents.
• Carry identification with you.
• Inform us if you do not understand any part of your treatment. Ask questions and take part in your
healthcare decisions.
• Inform us when you are having pain or when your pain is not being managed.
• Respect the Center’s property and equipment.
VOICE YOUR CONCERNS OR SUGGESTIONS
Without fear of reprisal, voice grievances regarding treatment or care, changes in policy and service, or
other comments to:
The Center:
Attn: Clinical Director
Kansas City Surgery Center
7524 Antioch Rd.
Overland Park, KS 66204
Ph: (913) 382-4440
The State:
Kansas Department of Public Health is the agency responsible for ambulatory surgical centers’ complaint
investigation. Complaints may be registered with the department by downloading a form at:
https://www.kdheks.gov/bhfr/download/complaint_investigation_form.pdf
Complaints may be filed with the Health Facilities Program Director of the Kansas Department of Public
Health:
By mail: Bureau of Community Health Systems, 1000
SW Jackson, Ste 330, Topeka, KS 66612
By phone: 1-800-842-0078
By fax: (785) 559-4250
A complainant may provide his/her name, address, and phone number to the Department. All complaints are
confidential.
Medicare:
Office of the Medicare Ombudsman:
http://www.medicare.gov/claims-and-appeals/medicarerights/get-help/ombudsman.html
or 1-800-MEDICARE.
Financial Responsibilities:
As a patient of the Center, I understand that any co-pays, co-insurance, and/or deductibles are due prior to having my procedure. I understand that the following provider fees are NOT INCLUDED in the surgery center fee and will be billed separately:
• Physician (surgeon) fee
• Anesthesiology fee
• Pathology, if applicable
• Laboratory services, if applicable
For any questions or concerns, please call (913) 382-4444.
OWNERSHIP DISCLOSURE
The owners of the Center are:
• Fred Bodker, MD
• Aaron Florkowski, MD
• Chris Ketcherside, MD
• Johann Ohly, MD
All directly have financial interests and ownership in the Center.
You have the right to choose your provider and where your procedure is performed. For any questions or concerns, please feel free to contact your physician.