Physician Ownership Disclosure
NOTICE TO PATIENTS
State law, A.R.S. 32-1401 (25) (FF), requires that a physician notify the patient that the physician has a direct financial interest in separate diagnostic or treatment agency to which the physician is referring the patient and/ or in the non-routine goods or services being prescribed by the physician, and if these are available elsewhere on a competitive basis. We support the law, because it helps patients make reasoned financial decisions concerning their medical care.
In compliance with requirements of this law, we have direct financial interest in the diagnostic or treatment agency or in the non- routine goods or services named below. Further, as indicated below, goods or services that we have prescribed are available elsewhere on a competitive basis.
DIAGNOSTIC OR TREATMENT AGENCY OR NON-ROUTINE GOODS AND SERVICES: AMBULATORY SURGICAL FACILITIES:
Are these available elsewhere on a competitive basis? YES
If yes which ones: Various hospitals and surgical centers in Maricopa County, Banner Desert is the closest facility.
The Law provides for the acknowledgement of your having read and understood these disclosures
By dating and signing this form in the space provided below upon receipt of your paperwork. We will keep this signed original in your patient file. Copies are provided if requested. I have been advised with written and verbal instructions, in advance of my scheduled surgery, a notice of my patient rights. I have also been informed of the ASC web-site, should I desire to download Advance Directive Forms.