For Patients

Driver Arrangements
A responsible adult must accompany you on the day of your surgery. Your escort needs to be prepared to stay at our facililty, drive you home and also stay with you after surgery as needed. Usually patients are at our facility about 2-3 hours on average.

We will provide courtesy transportation if you need it. Please communicate your need for transportation to our nursing or adminstrative staff so we can make scheduling arrangements.

Medications
If you take regular medications, ask your physician about taking them before surgery. If instructed to do so, take the medications with a very small sip of water.

Arrival Time
The day before your procedure, we will call you with your arrival time (and other pre-op information). Arrival time is when you are expected at Southgate Surgery Center, not the start time of your surgery. We cannot provide surgery start times. Please arrive promptly at the specified time.

Fasting Before Surgery
Diligently follow your surgeon's fasting requirements. Do not eat or drink anything after midnight before your procedure, unless directed otherwise. You can brush your teeth or rinse your mouth, but do not swallow any water. If you eat or drink anything (including water, mints or gum) after midnight, your surgery may be cancelled.

If you smoke or use other tobacco products, quit or cut down a few weeks before surgery. Consult with your physician as needed.

Follow any other instructions you are given by your physician, physician's staff or our staff. Colonoscopy patients will have a more rigorous fasting schedule and will receive separate instructions. Ask our staff if you need more information.

Rescheduling/Canceling Procedures
To reschedule or cancel your procedure, please notify us at least 24 hours in advance at minimum if possible.

Preparing or clearing your digestive tract of all its contents prior to your procedure is extremely important for achieving accurate results. Follow your doctor's instructions closely. Refer to our Bowel Prep FAQs page for more information or call to speak with a nurse.

Screening Colonoscopy The MiraLAX® - Gatorade - Dulcolax prep is our preferred, standard bowel preparation for a screening colonoscopy. It tastes good and is affordable to purchase over-the-counter.

"It's Time for Your Screening Colonoscopy" Prep Instructions

Dr. Singal Liquid Diet Instructions
Gastroscopy (EGD, Upper GI)
MiraLAX®
MoviPrep®
NuLYTELY®
Prepopik®
Suclear®
SUPREP®

Arrival & Check-In
When you arrive at Southgate Surgery Center, you will be greeted at the reception desk and asked to complete some informational papers and consent forms. Be sure to ask any questions you have about these papers. Please arrive promptly for check-in at the time our staff advises.

Pre-Op (Before Surgery)
After the check-in process is complete and our surgical team is ready to receive you, you will be escorted to our surgery preparation area (pre-op). Here you will be assessed and monitored by our nurses and technicians. Be prepared to be seen by an anesthesiologist and to be readied for your specific procedure.

During Your Procedure
You will be transported to the operating room by stretcher. If it was not begun earlier, anesthesia will now be administered. Sensors are placed on your chest and are attached to a monitor that shows your blood pressure, heart rate and oxygen or breath rate. You will be kept comfortable throughout your procedure.

Post-Op (After Surgery)
After your procedure, you will be taken to our recovery area. The person responsible for taking you home is invited to join you at this time. Here you will be monitored by our nurses and prepared for discharge. You will be offered a light refreshment and given discharge instructions including your follow-up appointment and your surgeon's contact information. Ask your driver to help you by listening to your discharge instructions as you will still be groggy from anesthesia. This is a great time to ask questions about your recovery process.

SOUTHGATE SURGERY CENTER
EFFECTIVE DATE: 06/04/10 REVISED 09/23/13

Click here for a downloadable version of this document.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact our Privacy Officer at the contact information listed at the bottom of this page.

Your medical information is personal. We are committed to protecting your medical information. We create a record of the services you receive here to provide you with quality care and to comply with certain legal requirements.This Notice applies to all the records of your care generated by our facility whether made by your personal physician or one of the facility's employees.

This Notice will tell you about the ways in which we may use and disclose your medical information. This Notice will also describe your rights and certain obligations we have regarding the use and disclosure of your medical information.

We are required by law to be sure that medical information that identifies you is kept private, to give you this Notice of our legal duties and privacy practices with respect to medical information about you, and to follow the terms of the Notice that is currently in effect.

How Southgate Surgery Center May Use and Disclose Your Medical Information
The following describes the different ways that your medical information may be used or disclosed by our facility. For clarification, we have included some examples. Not every possible use or disclosure is specifically mentioned. However, all of the ways we are permitted to use and disclose your medical information will fit within one of these general categories:

Treatment
We will use medical information about you to provide you with medical treatment and services. We may disclose medical information about you to doctors, nurses, technicians and other facility personnel who are involved in providing your medical treatment. We will ask for your permission before we disclose your health information that is about HIV or AIDS, mental health treatment, genetic testing, or substance abuse treatment.

Payment
We may use and disclose information about you so that the treatment and services you receive at our facility may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you received here so your health plan will pay us or reimburse you for the treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. You may restrict certain disclosures of your medical information to a health plan where you pay out of pocket in full for the health care item or service.

Health Care Operations
We may use and disclose medical information about you for facility operations. These uses and disclosures are necessary to run our facility and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in providing care for you. We may also combine information about many of our patients to decide what additional services the facility should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, and other personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning the identify of the specific patients.

Appointment Reminders
We may use and disclose information to contact you as a reminder that you have an appointment for treatment or medical care at our facility. Unless you object, we will leave messages for you on an answering machine or with someone who answers the telephone. You can ask us to use other methods and we will comply.

Treatment Alternatives
We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services
We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Research
Under certain circumstances, we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one procedure to those who received another for the same condition.

As Required By Law
We will disclose information about you when required to do so by federal, state or local law. For example, disclosure may be required by Workers' Compensation statutes and various public health statues in connection with required reporting of certain diseases, child abuse and neglect, domestic violence, adverse drug reactions, etc.

To Avert a Serious Threat to Health or Safety
We may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Health Oversight Activities
We may disclose information to a governmental or other oversight agency for activities authorized by law. For example, disclosures of your medical information may be made in connection with audits, investigations, inspections, and licensure renewals, etc.

Lawsuits and Disputes
We may disclose information for judicial or administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies.

Law Enforcement
We may release information about you if required by law when asked to do so by a law enforcement official.

Coroners and Medical Examiners
We may release medical information to a coroner or medical examiner to identify a deceased person or determine the cause of death.

Unless you object, we will also share relevant information about your care with your family or friends who are involved in your care. Decedent's family and/or friends will have access or may request copies of decedent's medical records when these individuals were involved in providing care or payment for care and we are unaware of any expressed preferences to the contrary.

Your Rights Regarding Your Medical Information
You have the following rights regarding the medical information our facility maintains about you:

Right to Inspect and/or Receive a Copy
You have the right to inspect and receive a copy your medical information within 30 days of your request. By law, we can have one 30-day extension of the time for us to give you access or copies if we send you a written notice of extension. If electronic copies are requested and are available, you will be provided with access to the electronics information in the electronic form and format requested, if it is readily producible, or, if not, in a readable electronic form and format as agreed to by you and the Surgery Center. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to your medical information, you may submit a written request that the denial be reviewed.

To inspect and/or request a copy your medical information, or for information regarding a denial review, submit your written request to our Privacy Officer at the address listed at the bottom of this page.

Right to Transmit
You have the right to request transmission of a copy of your medical information directly to another person you designate. The request must be made in writing to our Privacy Officer at the address listed at the bottom of this page. It must be signed by the requesting individual and clearly identify the designated person and where to send the copy of the medical information. We may charge a fee for the cost of copying, mailing or other supplies associated with your request.

Right to Amend
If you feel that medical information we have about you is incorrect or incomplete, you may ask us, in writing, to amend the information. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information and to others that you specify. If we do not agree, you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension.

To request an amendment, submit your writing request to our Privacy Officer at the address listed at the bottom of this page.

Right to an Accounting of Disclosures
You have the right to request a list of the disclosures that we have made of your medical information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations, disclosures with your authorization, incidental disclosures, disclosures required by law and some other limited disclosures. You are entitled to one list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we may have one 30-day extension of time, if we notify you of the extension in writing.

To request this accounting of disclosures, submit your written request to our Privacy Officer at the address listed at the bottom of this page.

Right to Request Restrictions
You have the right to request a restriction or limitation on the use or disclosure we make of your medical information. We are not required to agree to your request for a restriction. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, submit your written request to our Privacy Officer at the address listed at the bottom of this page.

Right to Request Confidential Communications
You have the right to request that we communicate with you only in a certain manner. For example, you can ask that we only contact you by phone or by mail. We will accommodate all reasonable requests, if you pay us for any extra cost.

To request confidential communications, submit your written request to our Privacy Officer at the address listed at the bottom of this page.

Right to Restrict Fundraising Communication
You have the right to opt out of any fundraising communications.

To opt out of fundraising communications, submit your written request to our Privacy Officer at the address listed at the bottom of this page.

Right to a Paper Copy of this Notice
You have the right to see or get a paper copy of this Notice.You may also obtain a printable copy of this Notice here.

To obtain a paper copy of this Notice, contact our Privacy Officer at the address listed at the bottom of this page.

Revisions to This Notice
We reserve the right to revise this Notice. Any revised Notice will be effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of any revised Notice in our facility and on our website. Any revised paper Notice will contain the effective date on the first page.

Other Uses of Medical Information
Other uses and disclosures of your medical information not covered by this Notice of Privacy Practices will be made only with your written authorization. If you provide us such an authorization in writing to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. You should send your revocation to our Privacy Officer at the address listed on Page 4. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.

Breach Notification
Southgate Surgery Center will notify affected individuals should there be a breach of patient's information such as unauthorized requisition, access, use or disclosure of unsecured/secured protected health information (PHI) without unreasonable delay but not later than 60 days after discovery.

Complaints
If you believe your privacy rights have been violated, you may file a written complaint with our facility or with the Secretary of the Department of Health and Human Services, Office of Civil Rights. Our facility will not penalize you in any way for filing a complaint. To file a written complaint with our facility, contact our Privacy Office at the address listed below. If you prefer, you can discuss your complaint in person or by phone.

Southgate Surgery Center
ATTN: Privacy Officer
14050 Dix-Toledo Road
Southgate, MI 48195
(734) 281-0100

The facility and medical staff have adopted the following list of patient rights. This list shall include but not be limited to the patient's right to:

(a) A patient will not be denied appropriate care on the basis of race, religion, color, national origin, sex, age, handicap, marital status, sexual preference or source of payment.

(b) An individual who is or has been a patient is entitled to inspect, or receive for a reasonable fee, a copy of his or her medical record upon request. A third party shall not be given a copy of the patient's medical record without prior authorization of the patient.

(c) A patient is entitled to confidential treatment of personal and medical records, and may refuse their release to a person outside the facility except as required because of a transfer to another health care facility or as required by law or third party payment contract.

(d) A patient is entitled to privacy, to the extent feasible, in treatment and in caring for personal needs with consideration, respect, and full recognition of his or her dignity and individuality.

(e) A patient is entitled to receive adequate and appropriate care, and to receive, from the appropriate individual within the facility, information about his or her medical condition, proposed course of treatment, and prospects for recovery, in terms that the patient or resident can understand, unless medically contraindicated as documented by the physician in the medical record.

(f) A patient is entitled to refuse treatment to the extent provided by law and to be informed of the consequences of that refusal. When a refusal of treatment prevents a health facility or its staff from providing appropriate care according to the ethical and professional standards, the relationship with the patient may be terminated, unless legal documentation is presented, upon reasonable notice, and with referral information for another healthcare provider.

(g) A patient is entitled to exercise his or her rights as a patient and as a citizen, and to this end may present grievances or recommended changes in policies and services on behalf of himself or herself or others to the facility staff, to government officials, or to another person of his or her choice within or outside the facility, free from restraint, interference, coercion, discrimination, or reprisal. A patient is entitled to information about the facility's policies and procedures for initiation, review, and resolution of patient complaints. Complaints can be sent to Michigan Department of Licensing and Regulatory Affairs, Bureau of Health Systems, Complaint Investigation Unit, P.O. Box 30664, Lansing, MI 48909, Fax# (517) 241-0093, or call Complaint Hotline at (800) 882-6006. For any questions, concerns or complaints, you may contact the Office of the Medicare Ombudsman at: here. The role of the Medicare Beneficiary Ombudsman is to ensure that Medicare beneficiaries receive the information and the help they need to understand their Medicare options and to apply their Medicare rights and protections.

(h) A patient is entitled to information concerning an experimental procedure proposed as a part of his or her care and shall have the right to refuse to participate in the experiment without jeopardizing his or her continuing care.

(i) A patient is entitled to receive and examine an explanation of his or her bill regardless of the source of payment and to receive, upon request, information relating to financial assistance available through the facility.

(j) A patient is entitled to know who is responsible for and who is providing his or her direct care, is entitled to receive information concerning his or her continuing health needs and alternatives for meeting those needs, and to be involved in his or her discharge planning, if appropriate.

(k) A patient is entitled to associate and have private communications and consultations with his or her physician or any other person of his or her choice. A patient's civil and religious liberties, including the right to independent personal decisions and the right to knowledge of available choices, shall not be infringed and the facility shall encourage and assist in the fullest possible exercise of these rights.

(l) A patient is entitled to be free from performing services for the facility that are not included for the therapeutic purpose in the plan of care.

(m) A patient is entitled to information about the health facility rules and regulations affecting patient care and conduct.

(n) A patient is entitled to be informed that some physicians on staff have a financial relationship with the surgery center because they are investors and own shares in the facility.

When a patient cannot make healthcare decisions on his or her own behalf, legally binding written instructions, called Advance Directives, may be used instead. Examples of Advance Directives including Living Wills, Durable Power of Attorney for Health Care, Do-Not-Resuscitate Orders and Declaration of Anatomical Gifts.

For more information about Advance Directives, dowload Michigan's Long Term Care Ombudsman Program Advance Directives: Planning for Medical Care in the Event of Loss of Decision-Making Ability.

Southgate Surgery Center's policy states that if you have an Advance Directive, you must inform us. We will place a copy of it in your medical record and we'll notify all members of your healthcare team. If you wish to discuss Advance Directives, you may contact your healthcare provider.

Advance Directive forms are available below or at the surgery center and must be completed prior to your procedure, should you elect to execute one.

  •  Durable Power of Attorney (DPOA) Form
  •  Living Will Form
  •  Do-Not-Resuscitate (DNR) Forms
  •  Anatomical Gift Form

Michigan Notice to Patients REQUIRED BY THE PATIENT SELF DETERMINATION ACT ("PSDA")

Distributed by the MDCH YOUR RIGHTS TO MAKE MEDICAL TREATMENTS DECISIONS

We are giving you this material to tell you about your right to make your own decisions about your medical treatment. As a competent adult, you have the right to accept or refuse any medical treatment. "Competent" means you have the ability to understand your medical condition and the medical treatments for it, to weigh the possible benefits and risks of each such treatment and then to decide whether you want to accept treatment or not.

WHO DECIDED WHAT TREATMENT I WILL GET?
As long as you are competent, you are the only person who can decide what medical treatment you want to accept or reject. You will be given information and advice about the pros and cons of different kinds of treatment and you can ask questions about your options. But only you can say "yes" or "no" to any treatment offered. You can say "no" even if the treatment you refuse might keep you alive longer and even if others want you to have it.

WHAT IF I AM IN NO CONDITION TO DECIDE?
If you become unable to make your own decisions about medical care, decisions will have to be made for you. If you haven't given prior instructions, no one will know what you would want. There may be difficult questions: for instance, would you refuse treatment if you were unconscious and not likely to wake up? Would you refuse treatment if you were going to die soon no matter what? Would you want to receive any treatment your caregivers recommend? When your wishes are not known, your family or the courts may have to decide what to do.

WHAT CAN I DO NOW TO SEE THAT MY WISHES ARE HONORED IN THE FUTURE?
While you are competent, you can name someone to make medical treatment decisions for you should you ever be unable to make them for yourself. To be certain that the person you name has the legal right to make those decisions, you must fill out a form called either a Durable Power of Attorney for Healthcare or Patient Advocate Designation. The person named in the form to make or carry out your decisions about treatment is called a Patient Advocate. You have the right to give your Patient Advocate, your caregivers and your family and friends written or spoken instructions about what medical treatment you want and don't want to receive.

WHERE CAN I GET A PATIENT ADVOCATE DESIGNATION FORM?
Many Michigan hospitals, surgery centers, health maintenance organizations, nursing homes, homes for aged, hospice and home health care agencies make forms available to people free of charge. You can also get a free form from various members of the Michigan legislature. Many lawyers also prepare Patient Advocate Designations for their clients. The forms aren't all alike. You should pick the one which suits your situation the best.

HOW DO I SIGN A PATIENT ADVOCATE DESIGNATION FORM SO THAT IT'S VALID?
All you have to do is fill in the name of the advocate and sign the form in front of two witnesses. But that's not as simple as it sounds, because under this law, some people cannot be your witnesses.

Your spouse, parents, grandchildren, and brothers or sisters, for example cannot witness your signature. Neither can anyone else who could be your heir or who is named to receive something in your will, or who is an employee of a company that insures your life or health. Finally, the law disqualifies the person you name as your Patient Advocate, your doctors and all employees of the facility or agency providing health care to you from being a witness to your signature. It is easier to make a Patient Advocate Designation before you become a patient or resident of a health care facility or agency. Friends or co-workers are often good people to ask to be witnesses, since they see you often and can, if necessary, swear that you acted voluntarily and were of sound mind when you made out the form.

DO I HAVE TO GIVE MY PATIENT ADVOCATE INSTRUCTIONS?
No. A Patient Advocate Designation can be used just to name your Patient Advocate, the person you want to make decisions for you. But written instructions are generally helpful to everybody involved. And, if you want your Patient Advocate to be able to refuse treatment and let you die, you have to say so specifically in the Patient Advocate Designation document itself. Any other instructions you have you can either write down or just tell your Patient Advocate. Either way, the Patient Advocate's job is to follow your instructions.

CAN I JUST GIVE INSTRUCTIONS AND NOT NAME A PATIENT ADVOCATE?
Yes. You simply tell somebody, for example, your caregiver or your family and close friends, what your wishes are. Better yet, you can write what is called a "Written Will", which is a written statement of your choices about medical treatment. Even though there is not yet a state Living Will law, courts and health care providers still find Living Wills valuable. Those taking care of you will pay more attention to what you have written about your treatment choices, whether in a Patient Advocate Designation or a Living WIll, because they can be more confident they know what you would have wanted. Most doctors, hospitals, and other health care providers will also pay attention to what you've said to others, especially your family, about medical treatment. But again, it's better for everyone involved if you write your wishes down.

DO I HAVE TO MAKE A DECISION NOW ABOUT MY FUTURE MEDICAL TREATMENT?
No. You don't have to fill out a Patient Advocate Designation or a Living Will and you don't have to tell anybody your wishes about medical treatment. You will still get the medical treatment you choose now, while you are competent. If you become unable to make decisions, but you've made sure that your family and friends know what you would want, they will be able to follow your wishes. Without instructions from you, your family or friends and caregivers may still be able to agree how to proceed. If they don't, however, a court may have to name a guardian to make decisions for you.

IF I MAKE DECISIONS NOW, CAN I CHANGE MY MIND LATER?
Yes. You can give new instructions in writing or orally. You can also change your mind about naming a Patient Advocate at all and cancel a Patient Advocate Designation at any time. You should review your Patient Advocate Designation or Living Will at least once a year to make sure it still accurately states how you want to be treated and/or names the person you want to make decisions for you.

WHAT ELSE SHOULD I THINK ABOUT?
Treatment decisions are difficult. We encourage you to think about them in advance and discuss them with your family, friends, advisors, and caregivers. You can and should ask your facility or agency about their treatment policies and procedures to be sure you understand them and how they work. If you want more information about a Patient Advocate Designation or Living Will, or sample forms, please ask your caregivers for assistance. Many facilities and agencies have staff available who can answer your questions. Additional materials may be available from your State Representative or Senator.

Southgate Surgery Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Southgate Surgery Center does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Southgate Surgery Center:

Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters

Provides free languages services to people whose primary language is not English, such as qualified interpreters

If you need these services, contact Linda Phillips, R.N., Administrator at 734-281-0100.

If you believe that Southgate Surgery Center has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Linda Phillips, R.N.
Administrator
Southgate Surgery Center
14050 Dix-Toledo Rd.
Southgate MI 48195
(P) 734-281-0100 (F) 734-281-7447 [email protected]
You can file a grievance in person, by phone, fax, or email.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Ave. SW Room 509F
HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7679
(TDD) Complaint forms are available here.