Aliʻi Ambulatory Surgery Center

• Be sure to follow any specific individual instructions given to you by your physician before coming to the Surgery Center (lab work, EKG, etc.).
• Please obtain any special appliance or object instructed by your surgeon (crutches, brace etc.) prior to your day of procedure.
• If you have an allergy to latex, sleep apnea or an implanted internal defibrillator please notify the Surgery Center staff as soon as possible (call: 808-331-7960).
• A nurse from the Surgery Center will contact you before the day of surgery. The nurse will confirm the time you are expected to arrive and give you specific instructions to prepare you for surgery.

YOU ARE REQUIRED TO HAVE SOMEONE DRIVE YOU HOME AFTER THE PROCEDURE.
It is your responsibility to arrange, in advance, for a responsible adult to drive you home from the surgery center following your procedure. In order to ensure your safety, you will not be permitted to drive yourself home. You may not take public transportation alone afterwards. Sedation will slow down your reflexes so it is unsafe to drive.

Day of Procedure, Patient Responsibility & Instructions:

• DO NOT eat or drink (unless otherwise instructed by your surgeon and confirmed with our RN).
• DO NOT bring valuables or jewelry. We cannot be responsible for damaged or lost property.
• DO NOT wear your contact lenses; leave them at home and bring your glasses instead.
• BRING YOUR INSURANCE CARDS, DRIVER’S LICENSE OR OTHER PHOTO ID & METHOD OF PAYMENT IF DUE.
• BRING a list of all current medications with their dosages and strengths.
• DO TAKE your heart or blood pressure medications with a very small sip of water.
• Shower or bathe prior to your arrival using an antimicrobial soap (for example Dial Soap).
• DO NOT wear any lotion, creams, ointments or makeup on your face or body the day of your surgery.
• DO NOT use hair spray, hair gels or hair product on the day of your surgery.
• DO NOT use or wear perfume.
• REMOVE ALL body piercings/jewelry prior to your surgical procedure/day of surgery.
• Remove makeup and nail polish.
• Wear loose fitting clothing.
• BRING any items or equipment instructed by your surgeon or nurse such as crutches, brace or eye drops.
• Refrain from smoking or chewing tobacco on the day of surgery.
• Refrain from drinking alcoholic beverages 24 hours prior to surgery.

Services Available for Seniors

For more information visit Assisted Living In Hawaii Website Here

You may receive bills from several different providers for the care rendered to you at The Ali`i Ambulatory Surgery Center, LLC; including the Physician or Surgeon performing the procedure, Anesthesia Services (MedStream Anesthesia Group), The Ali`i Ambulatory Surgery Center, LLC, and laboratory – for any specimens obtained during your procedure.

Financial Agreement & Insurance
If you have insurance, we will help you receive maximum benefits by filing your insurance claim for you. However, payments for co-pays, co-insurance and deductibles will be collected at the time of service. We participate with several insurance companies, some of which are listed below. If yours is not listed, please contact us 808-331-7960 for details.

Participating Insurance

• Aloha Care Medicare Advantage
• Aloha Care Quest
• Blue Card
• Champ Va
• HMA, Family Health Hawaii (HMN)(**Operating Engineers Always Needs Prior Auth**)
• Hmaa
• HMSA (Quest, Ppo And Hmo)
• HMSA Akamai And 65C+
• Kaiser Added Choice Only (With Prior Authorization)
• Mdx Hawaii
  *Cigna
  *Aetna
  *Humana
• Medicare
• Multiplan/Phcs
• Ohana Medicare Advantage
• Ohana Quest (***Only Secondary To Medicare***)
• Pacific Southwest Administrator (Non Participating, Patient Will Pay In Full And May Possibly Get Reimbursed At Non Participating Rate From Insurance)
• Premier Eye Care
• Tricare
• Tricare For Life
• Triwest Healthcare Alliance Pc3
• UFCA
• UHA
• United Healthcare (Quest, Medicare Advantage, Ppo & Hmo)
• VA – Triwest (***Must Obtain Va Auth***)

A physician performing the procedure may have ownership interest in this facility. These procedures are performed at hospitals and other outpatient facilities in this community. You have the right to choose where to receive services, including a facility where your physician does or does not have ownership interest.

ADVANCED DIRECTIVES. You have the right to give instructions about your own healthcare. You have the right to name someone else to make healthcare related decisions for you with your Advanced Directives. If you are interested in learning more about Advanced Directives or establishing your Advanced Directives, please use the link for

RIGHTS AND RESPONSIBILITIES INFORMATION SHEET

Patients have

1. The right to quality care, privacy, treatment given with respect, consideration, and dignity.
2. The right to the privacy of information regarding patient’s diagnosis, treatment options, communication, and the potential outcomes of the treatment as well as access to information contained in his/her medical record.
3. The right to participate in decisions concerning care and treatment.
4. The right to know the physician performing his/her procedure may have financial interest or ownership in this ASC.
5. The right to be informed of patient responsibilities, conduct, and ASC rules affecting the patient’s treatment.
6. The right to knowledge of services provided at this facility.
7. The right to discharge instructions, including information about after hours’ care.
8. The right to detailed information regarding service fees and all charges.
9. The right to refuse participation in experimental research.
10. The right to receive the policy on advance directives and living wills in the facility and to be given information upon request
11. The right to knowledge of the medical staff credentialing process, upon request.
12. The right to know the names of those treating the patient.
13. The right to truthful marketing or advertising utilized by the facility.
14. The right to be informed if the physician does not carry malpractice insurance.
15. The right to address a grievance.
16. The right to refuse a treatment, as permitted by law. One can refuse treatment and still receive alternate care.
17. The right to be fully informed regarding one’s condition, understand that information, and sign an Informed Consent form before receiving care
18. The right to appropriate assessment and management of pain.
19. The right to continuity of care. If overnight care is required, staff will arrange for transportation of a patient to the transfer hospital.
20. The right to respectful, safe care and treatment free from seclusion, restraints, abuse and harassment.
21. The right to have a family member notified of his/her admission as well as notification of his/her personal physician, if requested by the patient.
22. The right to express spiritual and cultural beliefs.

PATIENT RESPONSIBILITIES:

1. The patient is responsible for providing accurate/complete information related to his/her health; reporting perceived risks in his/her care, and for reporting unexpected changes in his/her health.
2. The patient and family are responsible for asking questions when they do not understand, what a staff member has told them about the patient’s care or expectations of what they are to do.
3. The patient is responsible for following the treatment plan established by his/her physician, including the instructions of nurses and other health professionals as they carry out the physician’s orders.
4. The patient is responsible for notifying the ASC office when unable to keep a scheduled appointment.
5. The patient is responsible for providing his/her healthcare insurance information, and assuring the financial obligations of his/her care are fulfilled as promptly as possible
6. The patient is responsible for the consequences if he/she refuses treatment or fails to follow the practitioner’s instructions.
7. The patient is responsible for being respectful and considerate of other patients and organizational personnel.

These rights and responsibilities outline the basic concepts of service here at the Kona Surgery Center. If you believe, at any time, our staff has not met one or more of the statements during your care here, please ask to speak to the Medical Director or Center Director. We will make every attempt to understand your complaint/concern. We will correct the issue you have if it is within our control, and you will receive a written response.

ADVANCE DIRECTIVES

Federal Law directs that any time you are admitted to a health care facility, you must be told about laws concerning your right to make health care decisions. This applies to all patients, no matter what their medical condition. You have the right to consent or refuse any medical care and treatment unless care is ordered by a court.

In an emergency, your consent to resuscitation (CPR), medical care, and treatment is assumed. In order to be in compliance with the Self-Determination Act (PSDA) and State laws and rules regarding advance directives, we will be asking if you have a living will. If you do not, this facility’s staff will offer you
information on how to make a living will. Because this is an ambulatory setting, any Advanced Directive to withhold resuscitation (CPR) will not be honored while you are in this facility. Should you suffer a cardiac or respiratory arrest or other life-threatening emergency, this signed consent implies consent for
resuscitation and transfer to a higher level of care. Therefore, in accordance with federal and state law, The Kona Ambulatory Surgery Center is notifying you that we will NOT honor any previously signed advanced directives for any patient.

Report complaints to

State of Hawaii, Department of Health
Kailua Kona, HI 96740 Kapolei, Hawaii 96707
808-331-7960 808-692-7420

OR
* Office of the Medicare Beneficiary Ombudsman.
MEDICARE: 1-800-MEDICARE (OMBUDSMAN) @ www.cms.hhs.gov/center/ombudsman.asp