Welcome to Southgate Surgery CenterYour doctor has determined that you require surgery. This information will help answer your questions and provide you with the necessary information about your upcoming procedure. This will guide you through pre-operative surgery and post-operative care. Knowing what to expect will help alleviate fear and make you more comfortable. This information also provides you with information we are required to make available to you as mandated by state and federal authoriites.

We care about your questions and concerns. Please feel free to discuss them with the healthcare team at Southgate Surgery Center. Everything you need to know can be found in the directory to the left of this text.

Your Experience at Southgate Surgery CenterYou are going to have same-day surgery (also called ambulatory or outpatient surgery). At Southgate Surgery Center, we provide high quality, patient-focused care.

From the time you come through our doors until you leave, you will appreciate the quality and professionalism that our expertly trained team provides. We work hard to make each and every patient feel comfortable and at ease. If you have any questions, do not hesitate to contact us before your upcoming procedure.

Preparing for Surgery 1. Depending on your medical history, some tests may need to be done before surgery. You will be notified ahead of time by a member of your healthcare team if any additional tests are required; this will be well before your day of surgery.

2. If you take regular medications, ask your healthcare provider if you should take them before surgery. If instructed, take the medications with a small sip of water.

3. A staff member will call you the day before your procedure with instructions and arrival time. Arrival time is when you are expected at Southgate Surgery Center, not the start time of your procedure.

4. Arrange for a responsible adult to drive you home after surgery and stay with you afterward, as needed. This person should also be prepared to stay at the facility during your procedure.

5. Do not eat or drink anything after midnight before your procedure, unless directed otherwise. This includes water, mints and gum. You can brush your teeth or rinse your mouth, but do not swallow any water. If you eat or drink after midnight, your surgery may be cancelled.

6. If you smoke or use other tobacco products, quit or cut down a few weeks before surgery. Your healthcare provider may give you specific instructions.

7. Follow any other instructions you are given.

8. To cancel your procedure, we ask that you notify us at least 24 hours in advance.

The Day of the Surgery Checking 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.

Pre-Op (Before Surgery)
After checking in, you will be taken to a surgery preparation area (pre-op). Here you will be assessed and monitored by our nurses and technicians, be prepared for your specific procedure and be seen by an anesthesiologist.

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

Post-Op (After Surgery)
After your procedure, you will be taken to one of our recovery areas. 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. This is a great time to ask any questions.

Patient Rights 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 with prior authorization of the patient.

(c) A patient is entitled to confidential 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 received 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 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/her rights as a patient and as a citizen, and to this end may present grievances 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, overview, and resolution of patient complaints. Complaints can be sent to MDCH Bureau of Health Systems Complaint Investigative Unit, P.O. Box 30664, Lansing, MI 48909, Fax# (517) 241-0093, or call the Complaint Hotline at (800) 882-6006.

(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) Patient is entitled to associate and have private communications and consultations with his/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) The 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 of the facility.

Patient Responsibilities The care a patient receives depends partially on the patient themselves. Therefore, a patient has certain responsibilities as well. These responsibiliites shall be presented to the patient in the spirit of mutual trust and respect.

(a) The patient has the responsibility to provide accurate and complete information concerning his or her present complaints, past medical history and other matters related to his or her health.

(b) The patient is responsible for making it known whether he or she clearly comprehends the course of his or her medical treatment and what is expected of him or her.

(c) The patient is responsible for following the treatment plan established by his or her physician, including the instructions of health professionals as they carry out the physician's orders.

(d) The patient is responsible for keeping appointments and for notifying the facility or physician when he/she is unable to do so.

(e) The patient is responsible for his or her actions should they refuse treatment or not follow his or her physician's orders.

(f) The patient is responsible for assuring that the financial obligations of his/her care are fulfilled.

(g) The patient is responsible for following facility policies and procedures.

(h) The patient is responsible for being considerate of the rights of other patients and facility personnel.

(i) The patient is responsible for being respectful of his or her personal property and that of other persons in the facility and the belongings of the facility itself.

(j) The patient is responsible to present their Advanced Directives to the facility that are to be followed in the event he or she could not make their wishes known concerning emergency or life prolonging procedures.

Privacy Practices 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 (734) 281-0100.

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 the 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.

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 Worker�s 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.

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. 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 request to our Privacy Officer at
( 734) 281-0100.

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 request to our Privacy Officer at
(734) 281-0100.

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 request to our Privacy Officer at (734) 281-0100.

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 request to our Privacy Officer at 734-281-0100.

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 request to our Privacy Officer at (734) 281-0100.

Right to a Paper Copy of this Notice: You have the right to see or get a paper copy of this Notice. To obtain a paper copy of this Notice, contact our Privacy Officer at (734) 281-0100.

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 under Contact Us. 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

Patient Information Form Please fill out the form below or print the document and mail it to us.

Advanced Directives 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 and Do Not Resuscitate Declaration.

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 Advanced Directives, you may contact your healthcare provider.

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

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'M 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.

Financial Information Procedure Billing
We want to make payment of your account convenient for you by billing your insurance carrier on your behalf. To make this possible, it is necessary for you to supply us with your current insurance information. Depending on your insurance carrier benefits, coverage will be verified with the carrier prior to your procedure. You will be responsible for any co-pays and/or deductibles and will be billed for such balances. Outstanding balances over 90 days will be turned over to a collection agency.

Anesthesia Billing
Your anesthesia today will be administered by an anesthesia care team: or a certified registered nurse anesthetist (CRNA) and a physician anesthesiologist, who medically directs the CRNA. As such, depending on your insurance provider, you may receive two separate bills for the anesthesia services - one for the nurse anesthetist and one for the physician. Note that the total amount is the same whether the anesthesia is administered by a care team or by a single provider. Please direct any anesthesia billing inquiries to South Oakland Services at
(800) 860-7226

Doctor Shareholders at the Center
  • Marilyn Belamaric, MD

  • Lawrence Castleman, MD

  • Kamal Gupta, MD

  • Sham Gupta, MD

  • Gregory Katz, MD

  • Daniel Kozlow, MD

  • Julie Reno, MD

  • Sudarshan Singal, MD

  • David Tukel, MD

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