Patient Financial Responsibility

I authorize Arkansas Outpatient Surgery Center (and my representative thereof) to release any and all information that is necessary to any insurance company or companies, to my referring physician, family physician, any physician, as well as any other contracted providers who I may be referred. I agree this authorization will remain in effect until canceled by myself in writing. I authorize payment of benefits directly to Arkansas Outpatient Surgery Center for services rendered and understand that I am responsible for any claims denied by my insurance carrier(s) including co-pays, deductibles, or any additional fees put forth by Arkansas Outpatient Surgery Center. If my coverage is with an HMO, I will assume responsibility for obtaining a referral and/or number from my primary care physician and will be responsible for payment of services denied by my failure to obtain the referral. I am aware that this referral form and/or number is required prior to being examined. I give my permission to be contacted or a message left at the contact numbers on file about my appointment and/or treatment.


The surgeons in this practice have some ownership in Arkansas Outpatient Surgery Center. We respect the rights of our patients to choose not only their surgeon but also where they wish to have their surgery or procedure performed.