Patient Information

Welcome to the Southwest Surgical Suites Patient Information portal! You’ll likely have questions before, during, and after your procedure. Here you will find all the details, from what to wear to what to avoid in the hours leading up to your visit, all part of our goal of making you as relaxed and comfortable as possible.

Forms

These forms are required for your upcoming procedure. Please download, print, and fill out these forms, and mail them to our office 1 week before your procedure. This will help expedite the patient intake procedure and give you more time to completely fill out the information.

Patient History 
Medications 

The following forms are for your information only and do not need to be printed or returned:

Patient Rights 

Advance Directives 

Notice of Non-Discrimination

Payment and Insurance

Patient Billing and Payment Information 

At Southwest Surgical Suites, we do everything we can to make your payment or billing process easy and as smooth as possible. We know patients are most interested in understanding how much they will pay out of pocket for their care. We offer multiple ways patients can obtain an estimate for services at our center.

Good Faith Estimate

A patient may ask for an estimate of the amount he/she will be charged for a non-emergency medical service provided in this facility. The law requires that an estimate be provided within five business days of the request.

• Fees charged by Southwest Surgical Suites are in addition to your surgeon and/or anesthesia provider fees.
• You may be contacted by a Patient Accounts Representative before your surgery to go over any relevant insurance information and to answer any questions you may have.
• The Patient Accounts Representative can help obtain approval or pre-certification for your procedure, if necessary

If you do not have insurance or are paying cash for your surgery, you will be asked to submit payment on or before the date of your surgery, unless other arrangements have been made. You may also be asked to sign a financial agreement. Please remember that these arrangements are your responsibility and must be made prior to your surgery.

• If you have verified insurance, you will be asked to pay only your portion (your co-payment and/or deductible) on or before the day of surgery.
• We accept all major credit cards.
• We will bill your insurance provider for you. Any balance that your insurance provider does not cover is your responsibility.
• Hours 9:00 a.m. - 4:30 p.m., Tuesday - Friday.
• If you have questions about your bill or need to discuss special financial arrangements, please contact our office at 260-434-2022.

Personalized Estimates

Our billing staff is available to help you understand your health insurance benefits along with your share of the financial responsibility and give you an estimate for the cost of services we provide. This option will provide you the most accurate estimate. To speak with one of our billing specialist team members, you can call a team member at (260) 434-2022 Tuesday - Friday 9:00am - 4:30pm.  Please have the following information available:

• Detailed description of the procedure(s) being ordered by the doctor.
• Doctor’s name and phone number.
• Insurance information (if any), including insurance company name and phone number, policyholder name, policy number and group number located on the insurance card.

Our staff will provide an estimate that includes the following:

• The estimated financial responsibility for the procedure/services based on the standard charge for the procedure/services.
• Patients with health insurance will be quoted, upon request, an estimated amount that will be due to the Center based on deductible, co-pay or co-insurance amounts established by their health insurance plan.
• Patients who do not have health insurance will be quoted an estimated amount due to the Center that will include an uninsured discount.
• Charity care/financial assistance is not available through the ambulatory surgery center.

 Shoppable and Common Services Provided

(Not an inclusive list of procedures)

Please Note: By viewing this pricing information, you are acknowledging that your sole purpose of accessing this site is to create an estimate for the health care service. The pricing information provided by this tool is an estimate only. Southwest Surgical Suites cannot guarantee the accuracy of any estimate on this website. Nothing on this site guarantees eligibility, coverage, or payment by your insurance, or determines or guarantees the benefits, limits, or exclusions of your coverage. The pricing provided on this site are based on a Standard fee, including supplies, procedures, and facility fees. These estimates do not include any clinic, physician, or other professional fees, which are billed separately and directly by those entities. These estimates do not account for treatment decisions by your healthcare provider, unforeseen complications, additional tests, multiple procedures, surgeon specific implants, or service orders, or non-surgery center related charges, which may increase or decrease the cost of the services provided. Your final bill may differ from the information provided by this website. Southwest Surgical Suites shall not be liable for any inaccuracies related to this pricing information. The prices set forth in this estimate are subject to change at any time without notice. For additional information related to the details of your coverage and to confirm your payment responsibilities, deductible and other details of your insurance, please contact your healthcare insurance carrier. For information related to payment plans available please contact our billing office at (260) 434-2022.

Shoppable and Common Services

Patient Protections Against Surprise Billing

Your Right to a Good Faith Estimate