Get Clr-0003 Notice To Patients 02-11.pmd - Tucson Surgery Center

Filling out the CLR-0003 Notice To Patients form is an important step in ensuring you are informed about the financial interests of your health care providers. This guide will walk you through each section of the form to ensure you can complete it accurately and efficiently online.

Follow the steps to successfully complete your form.

1. Click the ‘Get Form’ button to obtain the CLR-0003 Notice To Patients document and access it in your preferred online interface.
2. Locate the section where you will fill in the date and time of your scheduled surgery or procedure at Tucson Surgery Center. Ensure that both fields are completed accurately.
3. In the space provided, enter the name of the referring physician who has a financial interest in the surgery center. This information is critical for your awareness of potential conflicts of interest.
4. Next, input the name of your surgeon in the designated area. This ensures you understand who will be performing the procedure.
5. Review the list of goods or services mentioned in the form, including outpatient surgery, GI procedures, and pain management. If there are other services that apply, specify them in the provided space.
6. Once all applicable fields have been filled out, proceed to the acknowledgment section. Read the statement carefully, confirming that you understand the disclosure.
7. Finally, sign the form in the space marked for the signature of the patient or guardian and date the form appropriately. You will retain a copy for your records.
8. After completing the form, save your changes and consider downloading or printing the document for your personal records. You may also share the document as needed.

Complete your documents online today to ensure your procedures are managed effectively.