General Information - Step 1

ASSIGNMENT OF INSURANCE BENEFITS: I hereby authorize payment directly to Sequim Same Day Surgery the benefits payable to me, but not to exceed the balance of the charges for this period of treatment.

AUTHORIZATION: I hereby authorize release of any medical information necessary to process this claim. I authorize Sequim Same Day Surgery to submit complaint to the insurance commissioner for any reason. I further authorize the release of medical information to those healthcare facilities and/or physicians who may be responsible for the patient's follow-up care. I understand that it may be necessary to test the patient's blood while in the Surgery Center to protect against possible transmission of blood-borne diseases such as Hepatitis-B or Acquired Immune Deficiency Syndrome (AIDS). If, for example, a Surgery Center employee or physician is stuck by a needle while drawing blood or sustains a scalpel injury, I understand and consent that the patient's as well as the employee's or physician's blood will be tested (as appropriate). I further understand that the blood will not be routinely tested for these diseases and the results of any testing will be kept confidential in accordance with the state law.

FINANCIAL RESPONSIBILITY: I understand that I am financially responsible to Sequim Same Day Surgery for any amount not covered by this authorization. Within 10 days, a claim will be filed with my insurance carrier. I will be notified when final action (payment, rejection, etc.) by my insurance carrier has been received by the Surgery Center. Payment will be expected within 10 days of that notice. In the event that this account is placed with an attorney or collection agency, the undersigned is responsible for collection fees, reasonable attorney's fees and court costs.

THIS CHARGE FOR YOUR PROCEDURE IS A FLAT FEE FOR THE USE OF THE CENTER. It includes the Operating Room, Pre- Operative and Post-Operative care and all supplies used. We do not itemize cost as we wish to keep the expense to a minimum. THIS DOES NOT INCLUDE PHYSICIAN'S FEES, ANESTHESIA CHARGES, PATHOLOGY FEES, RADIOLOGY FEES, AND LABORATORY FEES.

Health Perception & Health Management Pattern

1st Resp Party



Yes / No




Primary Insurance


Workers Compensation / L&I Information (please fill out COMPLETELY)
Yes / No


Motor Vehicle Accident / Third Party Liability / Lawsuit (please fill out COMPLETELY)
Yes / No

General Information - Step 2

ft, in.

Yes / No Recent illnesses / hospitalizations, infectious diseases or history of cancer
Yes / No Heart Disease, Murmurs, Valvular, Pacemakers, AICD, MI, Stents,
HTN, Angina, Dysrhythmia
Yes / No Asthma or Breathing Problems, COPD, Obstructive Sleep Apnea
CPAP, Home Oxygen
Yes / No Hepatitis or Liver Problems
Yes / No GI Disorders, GERD, PUD, Hiatal Hernia, Crohns, Colitis, IBS,
Hemorrhoids, Diverticulosis
Yes / No History of Colon Polyps. Adenomatous Hyperplastic Unsure
Yes / No Kidney Problems, Renal Problems, Bladder Problems, Prostate
Yes / No Neurological Problems, Strokes, Seizures, Parkinson's, MS
Yes / No Bleeding Disorders, Anemia, Clotting Disorders-DVT
Yes / No Recent Illnesses/ Hospitalizations/ Other Illnesses or Infectious Diseases, Cancers
Yes / No Are you Pregnant? LMP , Pregnancy Tests
Yes / No Diabetic: Insulin Oral Med Diet Insulin Resistant THYROID problems
Yes / No Previous Surgeries/Procedures-List
Yes / No H/O Anesthesia related problems: N&V, Adverse Reactions, High Fever,
Family or Self
Yes / No Smoke? Packs per day for Years. Quit years ago.
Yes / No Drinks alcohol. Rare, Occasional, Weekly, Daily
Yes / No Glasses: Reading All the time Contacts
Yes / No Glaucoma
Yes / No Dentures, ( Upper, Lower) Bridges, Crowns, Loose Teeth
Yes / No Back Knee Problems
Yes / No Hearing Aides Right Left Hearing aids left at home
Discharge planning
Who will be driving you home?
You must have someone to drive you home if you are receiving anesthesia. The person taking care of you should be here for instructions before you are released.
We prefer you to have someone with you for 24 hours after surgery.


May we give instructions related to your,care with the person noted above?
Yes / No

Medications / Allergies - Step 3

Allergy List Reactions

Medications, Herbs & Supplements
Medication/Herb/Supplement Dosages/Freq. Reasons for taking medications

I have read and understand the Patient Rights and Notices. (View)

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