Lincoln Surgical Hospital has forms that must be completed prior to receiving surgical services. The information obtained will be utilized to help Hospital staff understand the patients’ health history and personal information. The information on the form(s) is kept confidential and can be completed by the patient or by the Hospital staff. Completed forms can be returned via fax, mail or in person.
Click on the appropriate form to view or print:
- Financial Assistance Application
- Medical Record Release Form
- Patient Portal Proxy Access Form
- Patient Rights and Responsibilities
- Pre-Surgery Questionnaire
- Disclosure of Physician Ownership
- Advance Beneficiary Notice – English
- Advance Beneficiary Notice – Spanish
The price transparency policy of Lincoln Surgical Hospital is to allow our patients to obtain our standard charges in compliance with the Centers for Medicare & Medicaid Services (CMS). This policy is aimed to promote price transparency for patients in order to help them understand their potential financial liability for any service provided at our hospital, and to allow consumers the ability to comparison shop for similar services across hospital providers.
On August 2, 2018, CMS issued final rule (CMS-1694-F) updating Medicare payment policies specifically requiring hospitals make available a list of their current standard charges via the Internet in a machine readable format and to update this information at least annually.
Average Claim Charges for Inpatient and Outpatient Procedures are comprised of all hospital facility charges reported on patient claims when the surgical procedure listed in the description is the primary procedure performed. These charges are inclusive of (but not limited to) surgical procedures, supplies, medications, implants, lab, radiology, physical therapy, occupational therapy, respiratory therapy, operating room, recover room, procedure room and patient room. Professional services provided (surgeon, anesthesia provider, hospitalist, etc.) will be billed to you separately.
Lincoln Surgical Hospital is committed to providing a low cost, high quality surgical solution for our patients. Call us at (402) 484‐0922 to obtain an estimate of your financial liability.
In addition, The Healthcare Financial Management Association has developed a guide to help consumers get answers to questions about health care prices, compare prices for a particular service among providers, better understand, plan and manage out‐of‐pocket health care costs. The guide also helps consumers compare hospitals based on quality outcomes.