MIDTOWN SURGICAL CENTER PRIOR to your procedure date

MIDTOWN SURGICAL CENTER
1919 E. 18th Avenue, Denver, CO 802.06 (303) 32.2.-3993
Your procedure is scheduled on
, at
Please arrive at the Center at
PRIOR to your procedure date, Midtown Surgical Center will:
. Attempt to contact you regarding preparations for your procedure, as well as
discuss your rights & responsibilities as a patient, physicians who have ownership in
our facility, our grievance process, Advance Directives, and the informed consent
process.
. Attempt to contact you regarding your insurance and/or your financial obligations.
Or, you can call our insurance verification department at (720) 979-0010.
PRIOR to your procedure, YOU/THE PATIENT should:
. Review the contents of this packet and follow all instructions
. If the surgical center has not successfully reached you, please call Midtown
Surgical Center at least 3 days prior to your scheduled procedure, between 7:30
am - 4:00 pm, Monday - Friday at (303) 322-0991 or (303) 322-3993 and ask for
Capri, our Patient Pre-Operative Case Coordinator.
. Please log on to our website ww.midtownsurgicalcenter.com and
complete the on-line history form as soon as you are scheduled for your
you have access to the internet.
procedure, if
Please bring this packet of documents with you on the day of your procedure.
Midtown
~ Surgical Center
i 9 I 9 East 18th Avenue
Denver, Colorado 8020(i
303.322.3993 Phone
303.322.7329 fax
www.Hl'althONEasc.col1
Dear Patient of Midtown Surgical Center,
As a Medicare licensed surgery center, we are federally required to provide in writing, as
well as discuss with you the following information prior to your procedure: your rights
& responsibilities as a patient, physicians who have ownership in our facility, Advance
Directive information, our grievance process and the informed consent process.
Inside this envelope, you will find all the written information we are federally mandated to
communicate to you. Please read it, complete and sign the necessary documents, and
bring all of it with you to the surgery center on your surgical day.
If you have not heard from Midtown Surgical Center within two (2) days of your
procedure, please call us so that we can go over this information with you. Our business
hours are 7am - 4pm, Monday through Friday. Please call (303) 322-0991 or (303) 3223993 and ask for Capri.
Thank you in advance,
Midtown Surgical Center
Midtown
~ Surgical Center
ll) I l) East i 8th Avenue
Denver, Colorado 8020Ei
303.322.39l13 Phone
303.3227329 fax
www.HealthONEasc.col1
Welcome to Midtown Surgical Center. We're very pleased that you and your
physician have chosen us to care for you.
We recommend that you enter your medical history online as soon as your
surgery has been scheduled. Once you do this, our nursing staff will be able to
access the information you entered online. This information will assist nursing
staff in organizing and documenting your complete medical history to prepare for
your surgery.
To begin,
1) Go to our website: http://www.midtownsurgicalcenter.com/
2) Select "Medical History" on the front page.
3) Click "One Medical Passport"
4) Accept the terms of use and click "Register"
5) Complete the registration and medical history screens, click Finish to submit
your Medical Passport to the medical facility
Be sure to have the following information available before starting your Medical
Passport:
· Your health insurance information.
. The names, addresses and phone numbers of your physicians.
. A list of all medications you are taking, their dosage and frequency.
. A list of surgical procedures you have ever had and their approximate
dates.
. This is a secure web site shared only with your treatment team.
. Returning patients will be able to update an existing passport at any time.
Note: If you are not able to complete your history online, please call our Preoperative case coordinator Capri between 7:30 and 4:00 Monday-Friday at (303)
322-0991 or (303)322-3993 as soon as possible to complete your health history.
You wil stil need to have the above information available when you call. Please
allow 20-30 minutes for this call.
Midtown Surgical Center
RIGHTS OF PATIENTS
The medical staff and personnel of Midtown Surgical Center recognize the basic human rights of
patients. Efforts are directed to providing care commensurate with those basic human rights.
Patients have the right to:
. Be infonned of his or her rights as a patient in advance of receiving care. The patient
may appoint a representative to receive this infonnation should he/she so desire.
. Exercise these rights without regard to sex or cultural, economic, educational or
religious background or the source of payment for care.
. Considerate, respectful and dignified care, provided in a safe environment, free from
all fonns of abuse, neglect, harassment and/or exploitation.
. Access protective and advocacy services or have these services accessed on the
patient's behalf.
. Appropriate assessment and management of pain.
. Knowledge of the name of the physician who has primary responsibility for
coordinating his/her care and the names and professional relationships of other
physicians and healthcare providers who will see him/her. The patient has a right to
change providers if other qualified providers are available.
. Be advised if the physician has a financial interest in the surgery center. A list of
physician investors is available upon the patient's request. The doctor perfonning
your procedure at Midtown Surgical Center has a financial interest in this facility.
. Be advised as to the absence of malpractice coverage.
. Receive complete infonnation from his/her physician about his/her diagnosis, illness,
course of treatment, risks, benefis, alternative treatments, outcomes of care
(including unanticipated outcomes), and his/her prospects for recovery in tenns that
he/she can understand. Your physician should discuss these with you prior to the
procedure and give you the opportunity to ask any questions you may have.
. Receive as much infonnation about any proposed treatment or procedure as he/she
may need in order to give infonned consent or to refuse the course of treatment.
Except in emergencies, this infonnation shall include a description of the procedure
or treatment, the medically significant risks involved in the treatment, alternate
courses of treatment or non-treatment and the risks involved in each and the name of
the person who will carry out the procedure or treatment.
. Participate in the development and implementation of his/her plan of care and
actively participate in decisions regarding his/her medical care. To the extent
permitted by law, this includes the right to request and/or refuse treatment.
. Be infonned of the facility's policy and state regulations regarding advance directives
and be provided advance directive infonnation, if requested.
. Full consideration of privacy concerning his/her medical care. Case discussion,
consultation, examination and treatment are confidential and should be conducted
discreetly. The patient has the right to be advised as to the reason for the presence
of any individual involved in his/her healthcare.
. Confidential treatment of all communications and records pertaining to his/her care
and his/her stay at the facility. His/her written permission will be obtained before
his/her medical records can be made available to anyone not directly concerned with
his/her care.
. Receive information in a manner that he/she understands. Communications with the
patient will be provided in a manner that facilitates understanding by the patient.
Written information provided will be appropriate to the age, understanding and
the language of the patient. Communications specific to the vision, speech, hearing
cognitive and language-impaired patient will be appropriate to the impairment.
. Access information contained in his/her medical record
within a reasonable time
frame.
. Be advised of the facility's grievance process, should he or she wish to communicate
a concern regarding the quality of care he or she receives. The patient can file a
grievance with the facility's Administrator or Clinical Operations Manager at (303)
322-3993; or the patient can file a grievance with the Colorado Department of Public
Health and Environment at 4300 Cherry Creek Drive South, Denver, CO 80246 at
(303) 692-2800.
. Be advised of contact information for the state agency to whom complaints can be
reported, as well as contact information for the Offce of the Medicare Beneficiary
Ombudsman. WW. cms. hhs.gov/center/om budsman. asp
. Be advised if facility/personal physician proposes to engage in or penorm human
experimentation affecting his/her care or treatment. The patient has the right to
refuse to participate in such research projects. Refusal to participate or
discontinuation of participation will not compromise the patient's right to access care,
treatment or services.
. Full support and respect of all patient rights should the patient choose to participate
in research, investigation and/or clinical trials. This includes the patient's right to a
fully informed consent process as it relates to the research, investigation and/or
clinical triaL. All information provided to subjects will be contained in the medical
record or research file, along with the consent form(s).
. Be informed by his/her physician or a delegate of his/her physician of the continuing
healthcare requirements following his/her discharge from the facility.
. Examine and receive an explanation of his/her bill regardless of source of payment.
. Know which facility rules and policies apply to his/her conduct while a patient.
. Have all patient rights apply to the person who may have legal responsibility to make
decisions regarding medical care on behalf of the patient.
. All facility personnel, medical staff members and contracted agency personnel
penorming patient care activities shall observe these patients' rights.
Pt Initials
RESPONSIBILITIES OF PATIENTS
The care a patient receives depends partially on the patient him/herself. Therefore, in
addition to these rights, a patient has certain responsibilities as welL. These responsibilities
are presented to the patient in the spirit of mutual trust and respect:
. The patient has the responsibility to provide accurate and complete information
concerning his/her present complaints, past illnesses, hospitalizations, medications
(including over the counter products and dietary and herbal supplements) and
dosages, allergies and sensitivities, and other matters relating to the patient's health.
. The patient and family are responsible for asking questions when they do not
understand what they have been told about the patient's care or what they are
expected to do.
. 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. It is the patient's responsibility to notify the facility if
he/she has not followed the pre-operative instructions given by their physician and/or
facility personneL.
. The patient is responsible for keeping appointments and for notifying the facility or
physician when he/she is unable to do so.
. Provide a responsible adult to transport him/her home from the facility and remain
with him/her for 24 hours unless exempted from that requirement by the attending
physician.
. In the case of pediatric patients, a parent or legal guardian must remain in the facility
for the duration of the patient's stay in the facility.
. The patient is responsible for his/her actions should he/she refuse treatment or not
follow his/her physician's orders.
. The patient is responsible for assuring that the financial obligations of his/her care
are fulfilled as promptly as possible. Ultimate financial responsibility is the patient's,
regardless of the insurance coverage he/she may have.
. The patient is responsible for following facility policies and procedures.
. The patient is responsible to inform the facility about the patient's Advanced
Directives.
. The patient is responsible for being considerate of the rights of other patients and
facility personnel, to include being respectful of his/her personal property and that of
other persons in the facility.
. Patient's signature represents he/she has received written and verbal information
regarding physicians' financial interest in the Facility, Advance Directives, grievance
process and on the informed consent process prior to the day of their procedure.
Patient Signature:
Date:
MIDTOWN SURGICAL CENTER PATIENT CONSENT TO RESUSCITATIVE MEASURES
NOT A REVOCATION OF ADVANCE DIRECTIVES OR MEDICAL POWERS OF ATTORNEY
ALL PATIENTS HAVE THE RIGHT TO PARTICIPATE IN THEIR OWN HEALTH CARE DECISIONS AND TO MAKE
ADVANCE DIRECTIVES OR TO EXECUTE POWERS OF ATIORNEY THAT AUTHORIZE OTHERS TO MAKE DECISIONS ON
THEIR BEHALF BASED ON THE PATIENT'S EXPRESSED WISHES WHEN THE PATIENT IS UNABLE TO MAKE DECISIONS OR
UNABLE TO COMMUNICATE DECISIONS. THIS SURGERY CENTER RESPECTS AND UPHOLDS THOSE RIGHTS.
HOWEVER, UNLIKE IN AN ACUTE CARE HOSPITAL SETIING, THE SURGERY CENTER DOES NOT ROUTINELY
PERFORM "HIGH RISK" PROCEDURES. MOST PROCEDURES PERFORMED IN THIS FACILITY ARE CONSIDERED TO BE OF
MINIMAL RISK. OF COURSE, NO SURGERY IS WITHOUT RISK. YOU WILL DISCUSS THE SPECIFICS OF YOUR PROCEDURE
WITH YOUR PHYSICIAN WHO CAN ANSWER YOUR QUESTIONS AS TO ITS RISKS, YOUR EXPECTED RECOVERY AND CARE
AFTER YOUR SURGERY.
THEREFORE, IT IS OUR POLICY, REGARDLESS OF THE CONTENTS OF ANY ADVANCE DIRECTIVE OR
INSTRUCTIONS FROM A HEALTH CARE SURROGATE OR ATIORNEY IN FACT, THAT IF AN ADVERSE EVENT OCCURS
DURING YOUR TREATMENT AT THIS FACILITY 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 HEALTH CARE POWER OF ATTORNEY. YOUR
AGREEMENT WITH THIS POLICY BY YOUR SIGNATURE BELOW DOES NOT REVOKE OR INVALIDATE ANY CURRENT
HEALTH CARE DIRECTIVE OR HEALTH CARE POWER OF ATIORNEY.
IF YOU DO NOT AGREE TO THIS POLICY, WE ARE PLEASED TO ASSIST YOU TO RESCHEDULE THE PROCEDURE.
PLEASE CHECK THE APPROPRIATE BOX IN ANSWER TO THESE QUESTIONS. HAVE YOU EXECUTED AN
ADVANCE HEALTH CARE DIRECTIVE, A LIVING WILL, A POWER OF ATTORNEY THAT AUTHORIZES SOMEONE TO MAKE
HEALTH CARE DECISIONS FOR YOU?
o YES, I HAVE AN ADVANCE DIRECTIVE, liVING WILL OR HEALTH CARE POWER OF ATIORNEY.
o No, I DO NOT HAVE AN ADVANCE DIRECTIVE, liVING WILL OR HEALTH CARE POWER OF ATIORNEY.
o I WOULD LIKE TO HAVE INFORMATION ON ADVANCE DIRECTIVES.
IF YOU CHECKED THE FIRST BOX "YES" TO THE QUESTION ABOVE, PLEASE PROVIDE US A COpy OF THAT
DOCUMENT SO THAT IT MAY BE MADE A PART OF YOUR MEDICAL RECORD.
BY SIGNING THIS DOCUMENT, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS AND
AGREE TO THE POLICY AS DESCRIBED. IF I HAVE INDICATED I WOULD LIKE ADDITONAL INFORMA TlON, I
ACKNOWLEDGE RECEIPT OF THA T INFORMA TlON.
BY:
(PATIENT'S SIGNATURE)
Patient's Last Name:
Patient's First Name:
Date:
If consent to the procedure is provided by anyone other than the Patient, this form must be signed
by the person providing the consent or authorization.
I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND ITS CONTENTS AND AGREE TO THE POLICY AS DESCRIBED.
BY:
(Signature) (Print Name)
Relationship to Patient
o COURT ApPOINTED GUARDIAN 0 ATIORNEY IN FACT
o HEALTH CARE SURROGATE 0 OTHER
Midtown Surgical Center
Patient Consent to Resuscitative Measures
DEMOGRAPHIC INFORMATION
Name:
Age:
Date of Birth:
Sex:
Height:
Weight:
Age:
Home Phone:
Work Phone:
Mobile Phone:
Emergency Contact
Email:
Name of Person
Name:
Phone:
Address:
Completing Form:
Phone:
Legal Guardian: I . Yes
BMI:
Primary Language:
Needs Translator:
Phone:
Phone:
Phone:
Phone:
Specialty:
Specialty:
Specialty:
Primary Care Physician:
Specialist:
Specialist:
Specialist:
i
No
RIDE HOME INFORMATION
Phone:
Relationship:
Name:
Name of person who will care for patient after suroerv:
PREOPERATIVE INFORMATION AND EVALUATION
Planned Procedure:
Suroeon:
Current Prescription and Nonprescription Medications (include over the counter and vitamins)
Reason
Dose Frequency
Medication
Reason
Dose Frequency
Medication
Scheduled Date of Procedure:
Allergies
Medication Allergies
Reaction(s)
Reaction(s)
Other Allergies
Latex Products?
Adhesive Tape?
IV Contrast I xray dye?
Environmental Allergies?
Food Allergies?
Surgical/Anesthesia History
Surgery
Date (approximate)
Problems
o Malignant Hyperthermia 0 Pseudocholinesterase Deficiency 0 Postoperative nausea and vomiting (PONV)
o Motion Sickness 0 Other
(ê 2011. Medic;:l Web Technoloaies LLC
Patient Name/DOB:
REVIEW OF SYSTEMS
Cardiovascular
D Angina D Myocardial infarction D Congestive heart failure D Abnormal heart rhythm D High blood pressure
D Heart valve problems D Vascular disease D Pacemaker D Implanted Defibrillator D High cholesterol or
lipids D Coronary Stents D Bypass surgery D Other
Pulmonary
D Emphysema/COPD D Asthma D Pneumonia D Home oxygen use D Sleep apnea
Renal
D Tuberculosis D CPAP D Bronchitis D Shortness of Breath D Recent cough/cold D Smoker _ppd
D Other
D Kidney stones D Prostate trouble D Urinary incontinence D Kidney failure D Dialysis D Other
Hepatic
D Liver failure or yellow jaundice D Hepatitis D Cirrhosis D Alcohol use
Neurological
D Seizures D Stroke D Neuropathy D Frequent migraines that require treatment D Paralysis D Alzheimer's
drinks/day D Other
D Parkinson's D Other
Gastrointestinal
D Stomach ulcers D Frequent acid reflux or heartburn D Hiatal hernia of the stomach D Other
Hematological
D Anemia D Bleeding or blood clotting disorders D Blood transfusion D AIDS D Recent use of blood thinners
D Other
D Thyroid Disease D Cancer(s):
D Insulin Dependent Diabetes D Non-Insulin Dependent Diabetes D Other
Endocrinel
Metabolic
Musculoskeletal
D Musculoskeletal Problems D Arthritis D Chronic low back pain D Neck/Jaw problems
D Other
D Muscular Dystrophy D Implants/Joint replacement: Where
Psychiatric
D Bipolar disorder D Schizophrenia D Depression D Panic/anxiety attacks D Other
OB/Gyn
D Currently pregnant D Hysterectomy D Bilateral Tubal Ligation
DNA
Last Menstrual Period Date:
Other
D Glasses/Contact Lenses D HearinQ Aids D Chronic Pain, Pain Score:
(1-1 Q)
D Dental work: D Dentures D Bridges D Caps/crowns D Chipped/loose teeth
Illicit Drug History or Drug History (Marijuana, cocaine, etc.):
Contagious
Diseases
D MRSA, Date:
Child
D Normal growth and development D Abnormalities - Explain:
, How Treated:
D Other D None
Additional Comments or History Not Addressed:
Patient Signature:
Date:
Nurse Signature:
Date:
Comments:
This report is not intended to be added to the medical record, please enter this information into SourcePlus Passport and print a
Medical Passport for this patient. (Q 2011, Medical Web Technologies, LLC
~
l\lidtown
Surgical
Center
Financial Responsibilty Agreement
PATIENT RESPONSIBILITY:
Any fees collected at the time of service and any quotes regarding such fees are
estimated based on the information available to us at the time of service. We rely on
information provided by the responsible party regarding insurance coverage, information
from the responsible party's insurance company, and procedure fees associated with the
CPT codes scheduled/reserved and provided to us by your surgeon. This estimate does
not include the fees for the physician or anesthesiologist. There may be additional
charges should your surgeon perform a procedure that is different from, or in addition to,
what was scheduled, or for x-rays, implants, 23-hour observation, or other services which
were not scheduled or quoted prior to surgery.
PLEASE NOTE:
It is the patient's responsibilty to understand their individual insurance benefits.
PAYMENT ARRANGEMENTS:
Payment arrangements are available. Please ask about this option if you are interested.
Any payment arrangements should be arranged prior to services being provided.
BILLING PRACTICES:
Midtown Surgical Center will bill the responsible party's insurance company for facility
charges. Midtown Surgical Center will also collect any co-payments, co-insurance,
and/or deductibles at the time of service. The responsible party will be billed for any
remaining charges not covered by insurance, including co-payments, co-insurance and/or
deductibles. Additionally, the responsible party will be billed for facility charges in full
should the insurance company deny coverage due to lack of referral, no pre-authorization,
lack of proper reporting of incident/accident or lack of individual coverage, where
applicable.
COLLECTION ACTIVITY:
Any account balance that is not paid within 90 days of the date of service may be
forwarded to an outside agency for collection follow-up. Any account balance that
remains unpaid after this transfer may be eligible for reporting to a credit bureau. Should
litigation be necessary to collect an outstanding balance owed, the responsible party
agrees to pay all costs of collection including, but not limited to, collection fees, attorney
fees, interest and court costs.
If you have any questions, please contact the Central Business Offce at (720) 979-0010.
Thank you
for choosing Midtown Surgical Center.
Patient/Responsible Party:
Date:
SURGERY DO'S AND DON'T'S
DON'T eat or drink anything after midnight the night before your surgery (unless otherwise
instructed by your Dr. or anesthesiologist)
DON'T wear any jewelry or contact lenses, please wear your glasses. Wear loose fitting,
comfortable cloths.
DON'T forget to bring all your paperwork, photo ID and insurance card.
DO take your blood pressure or heart medication with just a sip of water the morning of your
surgery (unless otherwise instructed by your Dr.)
DO stop all herbal supplements and diet pills 2 weeks before surgery. If you take blood thinners
contact your surgeon for instructions.
DO contact your surgeon or PCP if you are diabetic, for instructions on when to take your
medications.
DO get crutches if needed-we DO NOT provide them.
DO make sure you have a ride home after your surgery and if you will be having general
anesthesia, you will need someone to stay the night with you after your surgery.
DO YOU HAVE AN ALLERGY TO LATEX
CONFIRM TIMES ONL Y WITH YOUR SURGEON!
PEDIATRIC PTS- No Consent to Resuscitate necessary and PARENT MUST be present in the
facility throughout the procedure.
Please call us at Midtown Surgical Center
with any questions
303-322-3993
TvEdto,..'o
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"WSurzi(:al
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You concentrate on gettinG weIJ...Walgreens pharmacywillCOnCtonlrate
on giving you top-quality pharmaceutical
care. Located atPresbyterianl
Plaza West
offer
(4th Floor), we
level of individualize service-ihcluding delivery of
medications to yourhospftalroom!*
SLLuke's Medical Center, Professional
you an exceptional
Walgreens pharmacy at
Professional Plaza West (4th Floor)
1601 E. 19th Ave., Suite 4650
Phone: 303c656-4656
Fax: 303-656-4660
Katey Morris
Pharmacy Manager:
Nearest 24-hour
Walgreens Location
2000 L Colfax
Ave.
I ntersection:Colfaxand Race
Phone: 303-331-Oe17
Fax: 303-331-8342
No bedside deliveries from this location.
Delivery Hours:
Monday through Friday,
S a.m. to 6 p.m.
Delivered within two
hours of request.
Fill in the information requested below and your nurse or case manager can fax in your prescriptions with
this form directly to our pharmacy. Thank you for choosing Walgreens.
Name
Check One: 0 Bedside delivery
Date of Birth
o Pickup at Walgreens located at
Physician's Name
o Delivery needed by _______
Presbyterian/St. Luke's Medical Center
Prescription Insurance Plan
Is there a caregiver/family member who you grant permission
Have you had a prescr'iption fiiled at any Walqreeri~, in riie
past 12 months? Circle one: Yes No
to assist you with your pharmacy needs? (if applicable)
Home Address
Caregiver Name _____~____~__~__
City, State
Caregiver Phone Number
Home or Cell Phone Number
Payment Information
Email
Credit ca rd num ber
List Any Drug Allergies
Exp. date ~_________________~
PACU Phone:
Please provide payment upon delivery.
zip
Nurse
CONFIDENTIAL HEALTH INFORMATION: Healthcare information is personal information related to a person's healthcare. It is being faxed to you after appropriate authorization or uncer circurr:::3r'r~-:'s I:-.c:l ,::i)r;'l r::qu:re i)i:t~,I)ri2CJl:c,li. YJli em:' o:.ii:;L1i,:,ct 1.,) rr~ir,tair' :t in .ì s,)f::, S~:'C'Jri~ .Jr~d cc,n~-í,::.:,ntìa: 'ii.,ji';n~t R,:.d:::c-l~;:L.r~ of th.s ir',¡.:,r,i,~~tii)r~ ;s pr:;rl:IJlli:,j '.,11:(-5:; ri.:;rr:iIU":~ 1.:1,,. ':'1' a~,pr:)p'ï;.J:'2
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dissemination, distribution or copying of this information is STRICTLY PROHIBITED.
If you have received this rr.essaqe in error, please notify us irrrrediately.
cz:Jí.cliO'..vQI'.~rc~.~nc:J. A;r,-Î'.ht.~l~sC-r'¡c~d. Of'!4C:3~; :1:8
Discharge Medication
Patient Information and Choice Letter
Dear Patient and Family:
Your physician has ordered medication for you after you leave the hospitaL. Walgreens pharmacy,
which is located in the Professional Plaza West on the 4th floor, can fill and deliver the medications
to your bedside, after your doctor decides to discharge you from Midtown Surgical Center.
Please note that you have the right to select any pharmacy to provide the medications ordered
by your physician. This service is provided as a convenience to you. This is your choice. If at a
later date you choose to move your prescription to another pharmacy, Walgreens will assist you
in this process.
If you need more information before making this decision, please ask one of our nursing staff on
the unit. If you wish to use the bedside delivery option please fill out the form below and give it
to your nurse. Your nurse will send the prescriptions to the pharmacy and they will deliver them
to your room.
Patient or Family: Please complete the following:
i hereby choose to use Walgreens Pharmacy
Nearest 24-Hour Walgreens Location
Walgreens Pharmacy at
Professional Plaza West (4th Floor)
2000 E. Colfax Ave.
1601 E. 19th Ave., Suite 4650
Intersection: Colfax and Race
Phone: 303~656-4656
Phone: 303-331-0917
Fax: 303-656-4660
Fax: 303-331-8342
Patient Signature:
Date:
Family Member / Guardian Signature:
Relationship:
Date:
Thank you for choosing Midtown Surgical Center for your healthcare needs!
..
Midtown
He.ilth Surgical Center
21-245 (03/10)