Important Patient Documents

If you are a new patient, please fill out the registration forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.

Insurances Accepted

Tri-County Surgical Associates & Dr. David W. Ford accepts all insurances. We are in-network in most and out-of-network in some others. We have no hidden surprises or tricky practices in our billing.

As part of your visit, we will be happy to help you by explaining your benefits and some of the many confusing terms that affect how much you end up paying. We promise to focus on clarity and simplicity for you.

Don’t let your uncertainty or fear of the insurance "unknown" keep you from experiencing our quality care. We will help you understand all of our costs, if there are any, that may be involved with your care before you make any treatment decisions.

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Cigna Health Insurance Logo
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Medicare/Medicaid CMS Logo

Patient Portal

HealthCare Portal facilitates better communication with your physician. Telehealth visits with many of our providers are now available! Let us know you are interested when you schedule your next appointment.

Patient Rights & Responsibilities

We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.

Welcome to our Practice.

Our commitment to you, our patient, includes the following rights. We comply with applicable Federal civil rights laws and affirm that we will deliver high-quality health care to every patient without regard to age, gender, disability, race, color, ancestry, citizenship, religion, pregnancy, sexual orientation, gender identity or expression, national origin, health condition, marital status, veteran status, payment source or ability, or any other basis prohibited by federal, state, or local law.

Considerate and Respectful Care

  • Fair, high-quality, safe, and professional care
  • Care regardless of color, race, religion, creed, etc.
  • Consideration, respect, and recognition of you and your individuality
  • Treatment privacy Safe environment Ask for (except in emergencies) a person of the same sex to be available for any part of an exam, treatment, or procedures performed by a person of the opposite sex
  • Not be undressed any longer than needed for the exam, test, procedure, or other reason
  • Private and discreet consultation, exam, and care. See Notice of Privacy Practices (NOPP) for the full list of privacy and security of health information/medical record rights
  • To wear appropriate personal clothing and religious or other symbolic items, as long as they do not interfere with your treatment or diagnostic procedures

Health Status and Care
  • Be informed of your health status in terms and/or language that you, your family, and caregivers can be expected to understand
  • Take part and be active in your care and treatment plan
  • Participate in decisions in your care, unless your doctors or others believe it is harmful to you
  • Know, be told, and understand:
    • The names, roles, and qualifications of your health care experts that provide your care
    • Your follow-up care
    • Risks, benefits, and side effects of all medicines and treatment procedures for your diagnoses
    • Innovative or experimental medicines and treatment procedures of diagnosis offered
    • Alternative treatment options offered
    • Your procedure and to “give informed consent” before it begins
    • Possible outcomes of your care and treatment
    • The assessment and management of your pain
  • When and if the Practice recommends other health care institutions:
    • To participate in your care
    • To know who these other health care places are and what they will do
    • To refuse their care
  • Get help from the doctor and others for follow-up care, if available
  • To change providers or get a second opinion, including specialists at your request and expense

Decision Making and Notification

  • Choose a person to be your health care representative or decision-maker
  • Exclude those you do not want help from or to join in your care or decisions
  • Ask for, but not have the right to demand, services the Practice does not think are needed or appropriate
  • Refuse treatment
  • Be included in experimental research only with your written consent
  • Refuse experimental research including new drug and medical device investigations
  • Receive the information necessary to approve a treatment or procedure
  • Give consent to a procedure or treatment

Ethical Decision

  • Talk to and join in with your doctor about:
    • conflict resolutions
    • withholding resuscitative services
    • foregoing or withdrawing life-sustaining care
    • investigational study or clinical trials
  • Know that if your health care expert decides your refusal to accept treatment prevents you from getting the right care (as stated by its ethical and professional standards), it can end the relationship

Access to Services

  • Receive free services of a translator, interpreter, or other necessary services or devices to help you communicate with the Practice in a timely manner (i.e. qualified interpreters, written information in other format or languages, etc.)
  • Bring a service animal except where prohibited pursuant to Practice policy
  • Have access to our facility buildings and grounds in compliance with The Americans with Disabilities Act, a law that stops discrimination against people with disabilities. The ADA policy is available upon request
  • A prompt and reasonable response to questions and requests for service
  • If you need any of the above services, contact the Practice management team at (843) 797-5151.

Payment and Administrative

  • Review your health care bill regardless of your ability to pay it or the payment source Receive information about available financial resources
  • If uninsured, to receive, before the provision of a planned nonemergency medical service, a reasonable estimate of charges for such service and information regarding any discount or charity policies for which the uninsured person may be eligible.
  • Know if the Practice, doctors and other team members accept Medicare, the government's health insurance for those aged 65+ or disabled
  • Know and understand the Medicare charges for your services and treatment provided
  • Receive if you ask, with explanation, a reasonable estimate of your health care charges before treatment
  • To be free from any requirement to purchase drugs, or rent or purchase medical supplies or equipment from any particular source (specifically in accordance with the provisions of the CA Section 1320 of the Health and Safety Code) and also to receive patient choice in these type of decisions

Protective Service

  • Receive available protective and advocacy services
  • Receive, as offered by state law:
    • care and treatment for mental illness or development disability
    • all legal and civil rights as a citizen
  • Understand and expect emergency procedures without unneeded delay within Practice scope
  • Get needed information to approve a treatment or procedure
  • Be given the Practice's policies and procedures for:
    • Initiation, review, resolution of patient complaints, including the address and phone number to file complaints
  • Discuss complaints, issues, or problems regarding discrimination in access to services with your doctor and/or the Practice management team/ Equity Compliance Coordinator at (843) 797-5151. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Equity Compliance Coordinator is available to help you.
  • File a complaint with the Ethics Line (1-800-994-6610), the Department of Health and Human Services*, Office of Civil Rights* or others with your concerns about patient abuse, neglect, misuse of your property at the Practice, other unresolved complaints, patient safety, and quality concerns Have a fair review of alleged patient right violations