Medical History & Nursing Agreement
Please use www.OneMedicalPassport.com to complete (fill-out) your medical history form as soon as possible. You will receive a phone call from an RN (2-5) days prior to your surgery and/or procedure date.
Please make sure we have a daytime phone number (Cell phone, if possible) where you can be reached.
Contact your family physician if you require lab work or an EKG.
Labs good for 30 days before surgery date. EKG good for 6 months before surgery date.
Note: All females ages 12-55 years with a uterus will have a pregnancy test day of surgery.
Please call 609-265-7800 the day before your procedure/surgery between the hours of 2:00 PM – 4:00 PM for your arrival time at the Memorial Ambulatory Surgery Center. Please call Friday if you are having surgery on Tuesday.
If you are taking blood thinners, aspirin, ibuprofen, motrin, advil, aleve, diet pills or herbal supplements, call your surgeon and/or physician for further instructions. Discontinue diet or herbal supplements two (2) weeks prior to surgery and/or procedure.
Do not eat or drink anything after midnight the night before your surgery, unless otherwise instructed by the pre-admission nurse.
On surgical and/or procedural day bring the following
- Insurance Cards
- Form of photo identification
- Co-Pay (due day of surgery/procedure)
- Payment Methods: Cash, Personal Check, Money Orders, Certified Check, VISA, MasterCard, or Discover Card.
- Contact Business Office at 609-265-7800 to discuss, if any, financial arrangements prior to surgery
Please take notice that the Facility bills under Virtua Health System’s insurance contracts and is considered in network with any contract Virtua Health System participates. If you have another carrier the facility may not be a participating provider with your insurance carrier and your upcoming procedure will be considered “out-of-network”. In either case you will be personally responsible for the co-payment, co-insurance, deductible, or other charges associated with your care for any services that are not covered by your insurance carrier. It is important that you contact your insurance company directly to obtain more information on your plan coverage and out-of-pocket costs
- If you develop a fever, cold, flu or any change in your condition 5 days prior to planned surgery and/or procedure, contact your surgeon.
- Make arrangements for someone (no cab or bus drivers) to drive you home after your surgery and/or procedure. Your driver should remain in the building until you are ready for discharge. A responsible adult must stay with you after surgery.
- Do wear comfortable clothing
- Do not wear make-up, jewelry (including wedding rings), cologne, or contact lenses. All body jewelry (including piercings) must be removed at home prior to surgery/procedure date.
- Do not bring valuables.
- Failure to adhere to any of these instructions may result in cancellation of your procedure.
- You will receive written discharge instructions.
- Free Wi-Fi access available in our lobby.
The Morris Anesthesia Group
GPO P.O. Box 26960
New York, NY 10087
Your Rights and Protections Against Surprise Medical Bills
What is “balance billing” (sometimes called “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 have to 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.
You are protected from balance billing for:
Certain services at an in-network ambulatory surgical center
When you get services from an in-network ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to anesthesia, pathology, laboratory, assistant surgeon, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities
Your health plan generally must:
Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of
Count any amount you pay for out-of-network services toward your deductible and out-of-pocket
If you believe you’ve been wrongly billed, you may contact 1-800-985-3059
Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the
Make sure to save a copy or picture of your Good Faith
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059
Our goal is to provide you with an excellent patient care experience.