The Southeastern Spine Institute

During the course of your physician/patient relationship, the Physician may at a future time refer you to Southeastern Spine Institute Ambulatory Surgery Center, LLC (“ASC”). The ASC is an ambulatory surgery center separate from Southeastern Spine Institute (“SSI”). The address of the ASC is Suite 100, 1106 Chuck Dawley Boulevard, Mt. Pleasant, SC 29464. The medical office of SSI is located just above the ASC at Suite 200, 1106 Chuck Dawley Boulevard, Mt. Pleasant.

In connection with any referral to the ASC. you are hereby advised that the Physician has an investment interest in the ASC.

You have the right and option to obtain the health care items and services for which the Physician may refer you to the ASC at any other ambulatory surgery center or hospital that provides ambulatory surgery procedures. Facilities in the Mt. Pleasant area that provide ambulatory surgery procedures include East Cooper Regional Medical Center.

By agreeing you acknowledge you have received, reviewed and understand this Physician/Patient Disclosure of Ownership Form. Further, by agreeing you acknowledge that should you be referred to the ASC, your agreement evidences your informed decision to decline the option to have the ambulatory procedure performed at one the above identified facilities, or any other unnamed facilities. Lastly, you further acknowledge that you agreed to the Physician/Patient Ownership Disclosure Form prior to the Physician’s referral of you to the ASC.